The Pandemic’s Mental Toll: More Ripple Than Tsunami

By | June 23, 2020

The psychological fallout from the coronavirus pandemic has yet to fully show itself, but some experts have forecast a tsunami of new disorders, and news accounts have amplified that message.

The World Health Organization warned in May of “a massive increase in mental health conditions in the coming months,” wrought by anxiety and isolation. Digital platforms such as Crisis Text Line and Talkspace regularly reported spikes in activity through the spring. And more than half of American adults said the pandemic had worsened their mental health, according to a recent survey by the Kaiser Family Foundation.

But this wave of new mental problems is still well offshore, and it could yet prove to be a mirage. Psychiatrists and therapists who work with people in the wake of earthquakes, hurricanes and other disasters noted that surges in anxiety and helplessness were natural reactions that seldom become traumatic or chronic. Surveys that ask people about their emotions are poor predictors of lasting distress, and the prevalence of severe mental disorders, like schizophrenia and bipolar disorder, are stable and very unlikely to have changed because of the pandemic. Most people living with these conditions needed continuous care before the virus took hold and will still need it when outbreaks are contained.

“In most disasters, the vast majority of people do well,” said Dr. Steven Southwick, a professor of psychiatry at Yale who has worked with survivors after numerous cataclysms, including mass shootings. “Very few people understand how resilient they really are until faced with extraordinary circumstances. In fact, one of our first jobs in these situations is to call attention to just that.”

Prescription trends provide little evidence of an explosion in mental disorders in recent months. In March, at the height of the epidemic in many regions, prescriptions for anti-anxiety drugs such as Xanax and Klonopin were up by 15 percent over February; antidepressants were up by 14 percent, and sleeping pills by 5 percent, according to data provided by OptumRx, the pharmacy benefit arm of UnitedHealth Group.

But those rates began to decline in early April. And the total prescriptions in that month were 8.7 million for anxiety drugs and 27.4 million for antidepressants — very close to their usual averages for April, according to data supplied by IQVIA, a health care analytics firm. Prescriptions for other categories of psychiatric drugs, like anti-psychosis medications, remained at average monthly levels through March and April.

“Modest transient rises in the use of antidepressant and anxiety medications allay concerns over the pandemic having driven steep increases in common mood and anxiety disorders,” Dr. Mark Olfson, a professor of psychiatry at Columbia, said in an email. The March bump in prescriptions for anxiety drugs in particular could partly reflect people stockpiling medications that they were already taking, or increasing their dosage, he said.

Credit…Niall Carson/PA Images, via Getty Images

In the wake of the Sept. 11 terror attacks, many health officials also were concerned about a wave of new mental disorders that might overwhelm the system. In a 2004 study, researchers dug into prescription data for the month before and after the terrorist attack, comparing prescription rates across a range of psychiatric drugs. “The acute shock and fear of the events of September 11 were not accompanied by a commensurate increase in the use of psychotropic medications,” they concluded, except for a modest increase in New York City.

The evidence from recent surveys asking people about their emotions during the pandemic is not convincing one way or the other either, experts said. One reason is that these surveys often do not make distinctions between people in the thick of the action — front-line workers, in this case — and everyone else. Millions of Americans have been juggling Zoom cocktail hours with Netflix binges: a time-management challenge, perhaps, but not one that has been linked to prolonged trauma.

Moreover, psychological distress usually takes time to consolidate into the kind of persistent condition that drives people to seek treatment, revealing a diagnosable psychiatric disorder. Generalized anxiety disorder, for instance, is defined in part by excessive anxiety for at least six months. Post-traumatic stress requires, first, experiencing a life-threatening event, either personally; through a loved one; or up close, like witnessing deaths in an intensive care unit. Nightmares and other reverberations of the trauma are common, but these typically must persist for at least three months to qualify for the full diagnosis of a chronic condition.

“There are a number of surveys out there, and I think they are all useful, to some extent,” said Emma Beth McGinty, an associate professor in the Johns Hopkins Bloomberg School of Public Health. “But they’re using a mishmash of measures of symptoms of depression and anxiety, and not a validated psychiatric instrument,” or questionnaire.

The best American survey to date, posted early this month by JAMA and led by Dr. McGinty, administered a standard, widely studied psychiatric questionnaire online to a nationally representative sample of 1,468 adults. It found that 14 percent of people had high levels of psychological distress, compared with an average of 4 percent during the pre-Covid era. It found little difference in respondents’ feelings of loneliness, compared to averages before the pandemic.

“The longer people experience these levels of psychological distress, the more likely they are to present with a diagnosis that would benefit from treatment,” Dr. McGinty said in a phone interview. “But the question of whether that’s really going to happen is an open one. We did this in early April, right as the shutdown and stay-at-home orders were implemented, when people were experiencing all this for the first time. One might hypothesize that the stress has eased, we’ve gotten more used to this and the world has opened up a bit.”

  • Frequently Asked Questions and Advice

    Updated June 22, 2020

    • Is it harder to exercise while wearing a mask?

      A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.

    • I’ve heard about a treatment called dexamethasone. Does it work?

      The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.

    • What is pandemic paid leave?

      The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

Dr. McGinty and her collaborators plan to conduct another such survey later this summer, she said, and possibly one in the fall, to see whether levels of psychological distress change as the epidemic changes shape through the year.

The fear of infection and disruptions caused by the coronavirus, without question, have intensified the distress of many individuals, especially those who have lost regular access to care as a result, or who had pre-existing dread of infections — from obsessive-compulsive disorder, for example.

“In my mind, since this started, there’s nowhere that’s clean,” said Naomi, a doctor in New York City who has a diagnosis of O.C.D.; she asked that her last name be omitted for privacy. “It was like a complete meltdown for me, because being a doctor, I know so much about pathogens and what can so easily happen.”

But when it comes to collective trauma of the chronic, disabling kind, many experts remain skeptical. Studies done in the wake of hurricanes, earthquakes and floods find that no more than 10 percent of people develop such prolonged reactions — and those are the people directly and intimately hit by the destruction. The other 90 percent pick up the pieces, and in time the nightmares and surges of panic recede.

Living through a pandemic is nothing like surviving a natural catastrophe such as those: it’s less visible, less predictable, a creeping threat rather than flying debris — a marathon, psychologically, rather than a sprint to safety. A wave of new mental health disorders may indeed be on the way, especially if Covid-19 cases explode again late in the year, or the economic downturn deepens.

But the evidence so far says nothing persuasive about whether it will be a tsunami or a ripple.

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