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Six-Months After COVID-19: The Pandemic and Mental Health

In the current news cycle, the words seem inextricably tied together: mental health and the pandemic, and the pandemic and mental health. The association is real, as documented in a new study in JAMA Network Open.

ACOG Frontline Voices: Members’ Stories from the COVID-19 Pandemic

The study's first author Catherine Ettman, chief of staff and director of strategic initiatives in the office of the dean at Boston University (Massachusetts) School of Public Health, shared three main findings with Health eCareers:

  1. One quarter of Americans reported depression
  2. This represents a three-fold increase over pre-COVID-19
  3. People with fewer resources were more likely to have depression

"This calls for a doubling down in our societal investment in supporting people through difficult economic times," said Ettman.

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The survey study included 1,441 respondents from during the COVID-19 pandemic and 5,065 respondents from before the pandemic. The findings aren't a major surprise to Ettman, or to others in the mental health arena, given the circumstances and given the history of mental health in this country.

"Fewer than half of U.S. adults who have any mental illness use mental health services," she said. "There is still a large gap in treatment care for those who could benefit from services."

As the Kaiser Family Foundation shared before the pandemic, nearly one in five U.S. adults ,or 47 million, reported having a mental illness during the past year, with 11 million reporting a serious mental illness.

The U.S. was indeed dealing with a mental health crisis well before the COVID-19 pandemic started, said Farris Tuma, MD, ScD, and chief of the National Institute of Mental Health Traumatic Stress Research Program.

"Almost 20% of adults reported one of more mental disorders in the prior year, and 5% fall into the category of significant impairment," he said.

"Approximately 40 to 50% of people with depression will get some kind of care, and wait about seven years to get it, and of that, 15% who get evidence-based care will find it has a positive effect on depression and anxiety."

Some have floated the term "mental health pandemic" to describe the effects the virus—and its resulting effects on aspects of life—has had on Americans.

"We found higher prevalence [of mental health problems] in the population after this event than has been documented after other large-scale traumas," said Ettman. "The reason for that is probably that this is not one event. This is due to both COVID and the fear and anxiety around COVID, as well as its dramatic economic consequences."

The word "disparity" also continues to come up in depression/COVID discussions.

"Evidence comes in particular from the disproportionate burden of depression on people with fewer resources," said Ettman. "The economic consequences of this moment may perpetuate stressors and therefore continue to increase depressive symptoms."

This calls for more attention to be paid to mental health problems arising in the moment that will need attention in coming months and years, she says. "More than half of U.S. adults reported mild depression or greater in April 2020. It is hard to say what will happen in the future."

In an unrelated study, the Well Being Trust and the Robert Graham Center predict as many as 75,000 more people will die from drug or alcohol misuse and suicide because of the pandemic.

A Mental Health Pandemic?

"The pandemic has definitely exacerbated so many conditions that even people who were not necessarily depressed or anxious are depressed or anxious now," says psychologist Mary Karapetian Alvord, PhD, at Alvord, Baker & Associates, LLC in Maryland. She is also an adjunct professor of psychiatry and behavioral sciences at The George Washington University School of Medicine and Health Sciences, in Washington, D.C.

"Those who haven't sought mental health in the past say they're isolated and afraid," she said.

Meeting the demand for services has been difficult, and not surprisingly, people in a "more tenuous" financial situation are having more problems finding access, she said.

"In our practice, we have a huge wait list, with people coming back and even with college students who haven't left [to go away to school] yet," Alvord said.

"Exposure to more stressors was associated with more poor mental health," Ettman said of her JAMA study.

Alvord agrees, adding that the more trauma a person suffers, the harder it is to get over that.

Long-term effects depend upon how much trauma a person has suffered and what kind it is.

"If a family member was on a ventilator for 60 days and then dies, and you weren't able to see them, a feeling of hopelessness runs through the family that is profound," she said. "If you're feeling isolated, that's different from someone who's lost a job—some restaurant owners have run their small business for 25 years [and have now lost their businesses]."

But, is there hope in all of this? Yes, there is, says Tuma.

"Based upon having carefully followed people after many kinds of traumas—disease and infectious disease, fear of loss of life, massive destruction, and economic hardships—we can be hopeful and optimistic," he said. "As we get control over the spread of the virus, expect there to be a substantial amount of recovery and lessening of many concerns related to the very common symptoms of depression and anxiety."

What You Can Do as a Provider

Tuma knows that many people will initially seek mental health help from their primary care provider, or if female, from their obstetrician/gynecologist.
"Someone who's functioning pretty well, anxious, or having some symptoms of depression may do well with self-monitoring, with self-care that helps them cope or manage on their own," he said.

Here are tips for professional colleagues from Tuma and Alvord to better navigate the waters of more patients likely divulging mental health challenges during COVID-19.

  1. Keep this (JAMA) study and others in perspective, says Tuma. "If we take clues from prior studies, we don't know if increasing rates during COVID will be enduring," he said. "Remember this is a picture in time and that the resilience of human beings is remarkable."
  2. If you're used to referring patients you suspect may have mental health needs, by all means continue to do that, he says. Integrative Collaborative Care models are proven very effective around mental health.
    If that's not something you do regularly, ask patients simple questions about how they are doing emotionally and socially in context with their medical visit. "They may say, yes, they're drinking too much, not able to get out of bed in the morning," he said. "Then you can connect that person to a mental health assessment if needed."
  3. If that's not something you do regularly, ask patients simple questions about how they are doing emotionally and socially in context with their medical visit. "They may say, yes, they're drinking too much, not able to get out of bed in the morning," he said. "Then you can connect that person to a mental health assessment if needed."

  4. A quick screening, says Alvord, could open the discussion door and involve questions such as:
    • Have you lost anyone close to you, or is anyone close to you ill with COVID?
    • What changes in work or family life are taking place and how are you coping with them?
    • What is your support system like? She says that two decades of literature on resilience shows that people who have a support system—friends, neighbors, fellow churchgoers—fare better than those who don't.
  5. Don't rule out telehealth, which has proven its efficacy, Tuma said. "We have super-strong evidence that cognitive behavioral therapy over the phone on a Zoom call is just as effective as sitting in a therapist's office."
  6. Take care of yourself and practice what you preach, says Alvord. "You'll have more energy to give to patients."
  7. Refer patients to the American Psychological Association's Psychology Help Center, a good consumer resource, she says. The Substance Abuse and Mental Health Services Association, or SAMHSA, also has extensive resources, especially for professionals like you, on its website.

Study Objectives Delineated

When asked what Ettman and colleagues hoped to accomplish with their JAMA study, the objectives are clear.

"First, we hope to raise awareness," she says. "Second, we hope that we can create more opportunities for screening, to identify patients who could benefit from care. Third, we hope to make treatment available, particularly for those with low resources. Policymakers and medical professionals should be aware of the increase in poor mental health, and that the people most at risk are more likely to experience the effects of this time on their health."

The study was funded by The Rockefeller Foundation–Boston University 3-D Commission and the National Institutes of Health (NIH).

In a similar vein, a study from the National Opinion Research Tracking Center (NORC) says psychological well-being suffered at the outset of COVID-19, but that things have leveled off. "Reporting of emotional and physical symptoms has remained stable in recent months, with the average person reporting about five out of 15 symptoms."

As might be expected, if you are preoccupied with COVID news, you'll have more symptoms than if not—watching, reading, talking about COVID, which is easy to do, given its prevalence.

Another report from the University of California, Irvine, which echoes findings of the other two studies, found that symptoms associated with acute stress and depression greatly increased between mid-March and Mid-April 2020—often considered the height of the pandemic. The research looked at more than 6,500 people and at preexisting mental and physical health, job and wage loss—as well as, again, media consumption.

The pandemic has clearly impacted much more than physical health, and researchers will continue to evaluate its effects that run beyond the obvious.

Article Originally Published on ACOG Career Connection

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