The end of the emergency phase of the pandemic is in sight in the United States, at least for now. But as the weight of the crisis is lifted, experts are also anticipating a long-term impact on people’s mental health.
For some people, the feelings of anxiety and depression that emerged during the pandemic will resolve as routines resume — people go back to the office, social connections are reformed, the seeming danger of activities dissipates. But others will face new or worse mental health issues that persist or even appear down the road, a number that could be quite large given the magnitude of despair and disruption. That burden, however big, stands to put an even greater strain on an already stretched mental health system.
“In the best of times, there is untreated mental illness,” said Susan Borja, the chief of the National Institute of Mental Health’s Dimensional Traumatic Stress Research Program. “Even a small increase in the rates of people with new or worsening mental illness is going to be a problem.” And with the pandemic, “it has been the entire country” facing new stressors, Borja said.
As the pandemic set in last March, the percentage of people reporting they felt anxious or depressed spiked and has remained elevated since, according to survey data. Experts have also highlighted increases in sleeping problems and alcohol and other substance misuse, and point to clear causes: Uncertainty and fear about the coronavirus itself; job loss and housing and food insecurity; juggling working from home while dealing with cooped-up kids; grief and a loss of social cohesion as a result of restrictions.
The question is what comes next. During emergencies, some people take on the mentality of just needing to get through it. When they have, though, the full weight of what they’ve been through can hit.
“At what point do we get to breathe?” said Theresa Nguyen, the chief program officer at Mental Health America. “And when you breathe, that’s when grief and processing can start to enter your mind.”
Mental health researchers have studied the impact of disasters, emergencies, and health crises for decades, going back to the 1942 Cocoanut Grove nightclub fire in Boston that killed nearly 500 people, said Carol North, a psychiatrist and director of the University of Texas Southwestern Medical Center’s Division of Trauma and Disaster. (The exception is wars, which have been investigated in various ways for hundreds of years.) That historical perspective provides the framework for how experts think about tail effects, but the pandemic has been unprecedented.
Natural calamities or disease outbreaks are typically geographically limited, and disasters or attacks are acute events. While fear lingers and recovery takes time, Covid-19 has become like a chronic stressor, one that has ebbed and flowed but hasn’t disappeared in the U.S. for over a year. It’s not just a health crisis either: The interventions instituted to slow the virus have resulted in massive upheavals in the economic and social fabric, a loss of financial security and emotional support.
“This one is worldwide,” North said. “How many events do we have that are worldwide? We have climate change, but that’s slower coming at us. The other thing is, how many things have caused so many secondary stressors?”
During the initial stages of a crisis, there can be a sense of rallying together. Think of the mass cheering for health care workers and the spirit of solidarity that imbued the first weeks of the pandemic. But as the pandemic dragged on — and the stressors compounded — it laid the groundwork for lasting issues for some people.
And just like with the virus itself, the psychological damage won’t be borne equally. Researchers say they worry about communities that were already more vulnerable to mental health issues, including LGBTQ+ people and those who face violence in their homes.
They also say that communities that the virus and subsequent economic fallout struck hardest, including Black, Latino, and Indigenous people, could see higher rates of mental health issues as a result. Experts noted that the pandemic overlapped with a bombardment of headlines about police killings of Black people and the movement against racial injustice — another source of stress.
Signs of the disparate impact are already starting to emerge. Preliminary data indicate suicides nationally dropped 5.6% from 2019 to 2020 (the early national figures do not yet include demographic details), but some states have seen higher suicide rates among people of color. One study in Maryland found the suicide rate doubled among Black people during the early months of the pandemic, while it was halved for white people. Researchers in Connecticut reported that while the suicide rate dropped 13% during the stay-at-home period, “a significantly higher proportion of suicide decedents were from racial minority groups.”
The shifts are particularly notable because white people nationally had higher pre-pandemic rates of suicide than Black or Latino people.
“They suffered from the pandemic the worst, and they are likely to have the longest tail of this,” said the NIMH’s Borja.
To many experts, the fact that the suicides dropped in 2020 came as a relief, but not necessarily as a surprise. Suicides often decline during wars and other crises, including the 1918 flu pandemic, said Christine Moutier, the chief medical officer of the American Foundation for Suicide Prevention. (Experts caution that the preliminary 2020 suicide numbers may change, particularly as death investigators have been overwhelmed with Covid-19. They also note that some portion of the record high number of overdose deaths were likely uncounted suicides.)
Studies have come to different answers on whether suicide rates rise after disasters, and if they do, when that increase occurs. People often experience a “honeymoon” phase after a crisis, while disillusionment takes time to settle in or symptoms of mental illness snowball.
The uncertainty about whether or when those mental health concerns might manifest is complicated by the ongoing uncertainty surrounding the pandemic itself, particularly as other parts of the world experience their worst outbreaks yet, and as economic damage is still being felt in the U.S.
“There are real science- and data-driven reasons to believe that the mental health ramifications and the potential for suicide risk elevation, that we haven’t seen the full scope of that yet,” Moutier said. “I am worried about that.”
What is clear, though, is that the pandemic’s far-reaching devastation could raise the risk of mental health issues for a number of groups, from health workers and those grappling with ongoing Covid-19 symptoms to caregivers and kids kept out of school for more than a year.
“If you think about natural childhood development, a year is a long time,” said Polina Krass, an adolescent medicine physician at Children’s Hospital of Philadelphia. “A lack of in-person schooling for many children, as well as the unprecedented level of socioeconomic stress faced by families, really distinguishes this crisis.”
Krass co-authored a study published last week that found that mental health conditions accounted for a greater share of pediatric emergency department visits during the pandemic compared to the years before. Those who showed up to the hospital were more likely to be admitted and to have longer hospital stays, a sign that preventive or routine mental health care was disrupted.
“Our fundamental question is, is this the tip of the iceberg?”
Polina Krass, adolescent medicine physician
“Our fundamental question is, is this the tip of the iceberg?” Krass said.
Some states and cities have reported increases in youth suicides in 2020, or that youth suicide rates remained flat while the rates for other age groups dropped. Experts caution, however, against forming conclusions from any one community’s experience. (Suicides, particularly among youth, are also relatively rare events, so small changes in raw numbers can look like big statistical jumps.)
There’s also concern about the long-term impact on the mental health of health care workers and essential personnel, who have been stretched to the limit for months at a time and exposed to so much suffering, all while fearing for their own safety. Studies have shown that past crises have contributed to burnout, substance misuse, and PTSD among health care workers, some of whom left their jobs amid the emergency or months down the road.
The question with the pandemic is what those consequences will look like on this far bigger scale: a longer tail of effects? A higher percentage of people affected? More acute symptoms?
“It should have been a priority before the pandemic, it needs to be a priority now,” said Jessi Gold, a psychiatrist at Washington University in St. Louis who focuses in part on health care workers. “If you care about your workforce, and you want your workforce to be happy and healthy and alive, you need to invest in mental health resources.”
Whatever increase in mental illness stems from the pandemic will fall onto an already under-resourced mental health system. Telemedicine became a more common option during the pandemic, and going forward could help increase bandwidth and expand access in underserved areas. The $1.9 trillion Covid-19 relief bill enacted this year also included funding for treating mental health and substance use disorders, school-based mental health programs, and supporting the mental health workforce.
But clinicians warn it’s not enough.
“We are incapable of serving this entire population,” Gold said. “We’ve never had a good system, and we’re going to have a system that’s only going to become more broken with this need.”
If you or someone you know is considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (Español: 1-888-628-9454; deaf and hard of hearing: 1-800-799-4889) or the Crisis Text Line by texting HOME to 741741.