The Mental Health Aftermath of COVID-19

John Whyte, MD, MPH; Jeffrey A. Lieberman, MD; Laurel S. Mayer, MD


May 15, 2020

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  • The next shoe to drop from COVID-19 will be the impact of the virus on mental health, including the effects of social isolation, the fear of the virus, and the pressures on healthcare providers.

  • On the basis of experience with other pandemics and natural disasters, as many as 50% of people may experience anxiety, depression, and some post-traumatic stress symptoms.

  • People who have preexisting mental health conditions, particularly anxiety, mood disorders, substance abuse, and obsessional or phobic disorders, will probably have an exacerbation of symptoms due to the pandemic.

  • If patients become anxious, irritable, worried, unable to concentrate, and unable to sleep, health professionals may want to recommend mental health counseling.

This transcript has been edited for clarity.

John Whyte, MD, MPH: We're in the midst of an epidemic, a mental health epidemic. Coronavirus has increased anxiety, depression, and PTSD. I sat down a little while ago with Dr Jeffrey Lieberman and Dr Laurel Mayer from Columbia University, who provide us with their insights as well as tips.

Dr Lieberman, why is the coronavirus causing this mental health epidemic?

Jeffrey A. Lieberman, MD: John, you're absolutely right. Not everybody quite appreciates that yet. But the coronavirus pandemic, which is largely an infectious disease that's a contagion that threatens many people's safety and lives, is the focus now. But this next shoe to drop in the aftermath of the contagion is going to be psychiatric in nature. And that's going to be a consequence of the stress that is placed on people as a result of the contagion, the fear of getting infected, the social isolation, the disruption to their lives. And it's also because of the massive pressure that it's placing on healthcare providers and even non-healthcare provider essential workers, like for transportation or for food and markets.

But beyond the effects of the virus itself, there is going to be such economic and social disruption in the aftermath that is going to be enduring, and this is going to take a huge toll on the mental health of the population. If we don't want to be caught unawares, like we were with the virus, we need to start thinking about that and taking action now.

Whyte: We've been talking about these deaths of despair. Dr Mayer, how prevalent do you think that's going to be, these suicides and other manifestations of despair?

Laurel S. Mayer, MD: I think we know from other pandemics, from other natural disasters, from other traumas that the rate of psychological symptoms after this is going to be quite high. As many as 50% of us may experience depression, may struggle with some post-traumatic stress symptoms, and will struggle with anxiety. And while most of us may actually do well, all of us will need something.

I mean, I sort of see mental health on a spectrum, where there's health and well-being on one end and illness on the other. So for most of us, we'll need support. We'll need some resiliency-building. We'll need some coping strategies to help us get through. And some will need more formal treatment because of issues like depression and substance use, which we know will also increase after disasters as we try to find ways to cope, some of which become healthier and some of which leave us in a different situation.

Whyte: Dr Lieberman, what are you seeing in terms of patients who perhaps have symptoms of PTSD but don't recognize it as PTSD? Or caregivers who don't recognize their symptoms or this manifestation relating to COVID because they're not thinking about that?

Lieberman: This is affecting everybody. But it affects people differentially depending on how close they are to the trauma of the infection. if you're working at an ICU, you're in ground zero. Did you lose a loved one who died? Are you going to lose your job as a result of this? And what is your preexisting psychiatric history? Do you have any constitutional and genetic vulnerability?

What we're seeing is that the worried well, so to speak, are freaked. And they need exactly what Laurel was describing in terms of mental health first aid to enable them to frame and understand this and then mobilize their internal strength for resilience.

Whyte: Do the worried well usually do okay?

Lieberman: If they get the guidance and support that they need. But the only way they can do that is if they're able to access virtual means of communication—you know, videos that have been posted on websites which provide guidance on how to decatastrophize and how to utilize your time and structure your day. But communication is necessary to do that. So there needs to be a public mental health initiative.

But the people who have preexisting conditions, particularly anxiety, mood, substance abuse, obsessional, or phobic disorders, are going to have an exacerbation of symptoms. And here's where virtual or telemedicine has finally been grasped and utilized to its full extent. So if you have a doctor or a therapist and you're having difficulty, you should feel free to reach out to them. You're not bothering them. And if they don't take your call, my advice is, get a new doctor or therapist.

Whyte: Dr Mayer, I wanted to bring up the point that a lot of folks want to look at it and say they can manage it. But for other people, they're drawn to the negative. And when we have social media and news media that—let's be fair—portrays a lot of doom and gloom, the negative stories, how do they cope with that? How do they break that attraction to the negative?

Mayer: I think one of the things that we've learned from this virus being so new is that it's sort of leveled the playing field. For some of us who thought, I don't need help; I can do everything on my own, that attitude doesn't really fly in the current situation. We all need help.

We need to figure out our new treatments. We need to figure out how this presents. We need to do work to get a vaccine. We need to ask our friends for help. And we need to know whether what we're experiencing is normal under the current conditions or whether there's something more going on. It's really critical that people reach out for help at this time, because as a community, we can move through this and survive this. It's going to require everyone pitching in.

Help comes in so many different forms now, whether it's the food being brought to the hospitals for the frontline workers, or someone being able to watch out for somebody else's kids while they go to work. There are ways in which we can be connected, help each other, and appreciate. Gratitude also goes a long way toward helping us stay positive to get us through this, and to help turn the tide to look toward the future.

Whyte: I wanted to ask both of you: What tips would you give people or caregivers to recognize when someone needs help? That's not always that easy for some folks. They think they're doing okay or they think everyone else is in the same place. What tips would you give folks?

Mayer: I think [that if you are questioning whether you] need help, reach out. Because just having that question says maybe you do. So ask.

Lieberman: I think that everybody benefits from it. When you say "needs help," you know, we're running a marathon. And the problem is that we can't pace ourselves because we don't know if the marathon's going be a half marathon, a full marathon, or an Ironman marathon.

And everybody, as Laurel said, needs help. To be COVID-safe, we have to be together-safe; we're not going to be able to do it alone because everything is interdependent. It is a great leveling effect in that sense.

In terms of what to look for, you don't even have to wait for the signs of stress. You know that you're going to wear down in some ways—some people worse than others—eventually. Just like when you move to a new town, you don't wait to get sick to get a doctor. You should get a doctor immediately so that when you get sick, you already have a relationship. This is going to be something that is going to test everybody.

It's the things that you need to look for that show symptoms of psychopathology, warning signs that people are experiencing more than they can handle. And it may occur in individuals who don't have preexisting disorders or vulnerabilities to those disorders, just as simply as they're becoming anxious, worried, can't concentrate, can't sleep, and are irritable. Or it may take the form of very specific symptoms that are ultimately going to reach the threshold of DSM diagnosis for depression, social anxiety, agoraphobia, for using substances to excess to self-medicate, becoming obsessionally germophobic, and things like that.

Whyte: So where should people go for help?

Lieberman: Well, people should be able to access mental health through the healthcare system that's available. So if you have a primary care doctor, you can start with that person and say, "I really need to see a psychiatrist or a psychologist. Is there somebody you can refer me to?"

In the absence of that, you look on the website of local—particularly the academic—medical centers. They should have means to call a hotline to first get screened and then referred. You should look online for mental health guidance, which is now proliferating in terms of the amount of [resources] for both stress and trauma, but also for grieving and loss.

Then, even in the absence of that, if you aren't able to make contact for whatever reason, reach out to friends and communicate with them, because that ability to connect with individuals, particularly those who are able to be supportive to you, can be helpful in and of itself.

But as Laurel said, don't wait. Don't hesitate. Err on the side of reaching out rather than waiting until you're thinking, It's so bad; I have to reach out.

Whyte: That's good advice. I want to thank you both for joining us.

Mayer: Thank you, John. Pleasure to be here.

Lieberman: Thanks, John. Keep up the good work.

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