COVID's Been a Mental Marathon, but Let's Not Hit the Wall Yet

Even if you haven't run a marathon, you've probably heard tales about "hitting the wall." Its effects are especially pronounced after passing the 25th mile with one final mile to go. The end is in sight, but mentally and physically, you're far from finishing the race.

Lloyd I. Sederer, MD

In recent months, we may have come to regard ourselves as being in the final mile of our battle against COVID-19. And the signs are indeed promising. The Centers for Disease Control and Prevention has confirmed that all adult Americans will be vaccinated against COVID (if they so choose) by the end of May. Those who have received any of the three vaccines currently approved by the US Food and Drug Administration (Pfizer, Moderna, and Johnson & Johnson) will be considered "fully vaccinated" 2 weeks after receiving their final shot. Blessedly for humans who like other humans, those fully vaccinated need not wear a mask or refrain from handshaking or hugs, outdoors or indoors.

Will mid-June, hence, be a time to declare COVID dead? Not so fast.

It only seems that we are approaching COVID's "last mile," but there are simply too many questions remaining. What percentage of the population is needed to achieve herd immunity? For how long will vaccines offer protection? How will we combat vaccine hesitancy in a country where measles went from eradicated to a renewed threat, and where rates of annual influenza vaccination among US adults have yet to reach 60%? If vaccinations remain unequally distributed among countries, what will this mean for the evolution of the COVID variants that are becoming predominant worldwide? What are the health ramifications for those so-called COVID "long-haulers," for whom nonrespiratory conditions can extend for months on end?

There are so many variables obscuring the finish line. One thing we can predict, however, is the tremendous psychiatric consequences of living through this moment in time. The coronavirus pandemic disaster already has produced increased rates of mental disorders, opioid and other drug overdoses, and suicides. Is more psychic suffering ahead? As President Abraham Lincoln once remarked, "The best way to predict the future is to create it."

Identifying Those Most at Risk During the 'Final Mile'

Disasters foster acute distress as well as a multitude of post-acute mental and addictive disorders, and COVID is surely a disaster. Effective treatment will require identifying those with the factors making them particularly vulnerable, including those with pre-existing mental or addiction disorders, traumatic histories, insufficient family supports, living in poverty and violence, lack of education and jobs, and limited access to healthcare (or lack of trust in doctors and hospitals).

The psychic trauma resulting from COVID remains understated and takes various forms. There is trauma from almost dying yourself or the death of a loved one. Trauma in healthcare workers and first responders who witnessed countless people die, despite their most earnest and selfless efforts. Trauma from seeing the refrigerated trucks used as morgues, too many to park away from view. Trauma from ceaseless work, powerlessness, fear of becoming ill or infecting one's family, from not knowing when this will end.

With trauma, our brains change. Circuits develop like ruts that cannot be escaped. These generate profound anxiety, unremitting vigilance, hyperreactive responses, and a litany of serious body ailments produced by the sustained release of cortisol. We now know a lot about serious mental trauma, including from childhood neglect and abuse, domestic violence, forced displacement, disasters, wars, plagues, and starvation. To that we can now add knowledge of COVID's persistent, menacing, and debilitating physical and emotional claws.

The best "treatment" for trauma is its prevention. That's the work we have ahead.

Let's Begin by Upending the Culture of Silence About Mental Health

Medical care too often suffers from a culture of "don't ask, don't tell," particularly between doctors and patients. It's not that these are "bad" doctors; instead, they face novel problems for which they were never trained, nor do they have readily accessible resources to turn to, or ones that are affordable to patients. And it's also not that patients are keeping secrets; many don't know themselves what's going on, and when they do suspect something, they often feel shame or blame for their disability or burden.

"Don't ask, don't tell" also happens between healthcare executives and their medical and nursing workforce, and between department heads and employees (both professional and nonlicensed). In each of these pairs, the former doesn't ask and the latter doesn't tell.

This is not a culture we should have endured before, and the current crisis has only escalated the need to upend it. As strained healthcare systems try to vaccinate in "the last mile," there are incredible risks to overlooking those individuals impaired and traumatized by COVID. They may remain silent, be it from not knowing, or shame, or fear of losing their job. Or they may be unable to face the gravity of their condition or not trust those offering help.

We need to make having frank and full conversations about cognitive functioning, mental and addictive disorders, trauma, and vaccine hesitancy the rule rather than the exception in healthcare. As long as the answers are kept hidden, we simply won't know what we don't know. Moreover, we can't fix what we don't know. It's akin to shooting in the dark.

What Can Change a Culture of Secrecy?

The process starts with unfiltered truths, delivered privately and anonymously, through a trustworthy means of collecting sentiments and ideas from enough people to be "statistically significant." These are the truths we need as guideposts for actions that can work — and demonstrably so, by employing selected measures of change that are meaningful, feasible, scalable, and sensitive to detecting the changes sought.

When individual and group ideas and sentiments go unsaid, they remain hidden from view. When experiences and ideas for improvement (including from healthcare and essential workers, students, teachers, and support personnel) are hiding, then solutions are wickedly elusive, ever more so today when the stakes are higher than ever.

The urgency and gravity of COVID demand that we not permit this fog to reign. The race is still being run. Instead of hitting the wall, let's scale it.

Lloyd I. Sederer, MD , is a psychiatrist, public health doctor, and writer. He is an adjunct professor at the Columbia University School of Public Health, director of Columbia Psychiatry Media, chief medical officer of Bongo Media, and chair of the advisory board of Get Help. He has been chief medical officer of McLean Hospital, a Harvard teaching hospital; mental health commissioner of New York City (in the Bloomberg administration); and chief medical officer of the New York State Office of Mental Health, the nation's largest state mental health agency.

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