The silent pandemic: mental health during and after COVID

COVID policies have been driving people to isolate, a key driver of loneliness and mental stress

 

It’s been two and a half years since the beginning of the pandemic. Life hasn’t been the same since, with talk of COVID boosters and potential mask mandates still lingering. Many states and cities moved on 18 months ago with relatively few restrictions on our mobility. Others always felt like they were on the verge of yet another mandate. Take for instance Los Angeles, suggesting potential indoor mask mandates for schools this fall. 

These wide-sweeping rules may seem well-meaning to some, but to others they’ve seemed  like they’ve been pursued arrogantly and in the face of many warnings. After all, it is these very same COVID policies that have been driving people to isolate, a key driver of loneliness and mental stress.  

To be sure, there was a mental health crisis in the U.S. before COVID hit the scene: in 2019, nearly 20% of adults, or nearly 50 million Americans, were already experiencing some form of mental illness, and there was already a growing problem among young people as well with more than 1 in 3 high school students having experienced persistent feelings of sadness or hopelessness in 2019, a 40 percent increase in 10 years. In the same timeframe, there was a 44% increase in youths who reported making a suicide plan. 

Whether that was an increase in people suffering, or just feeling more open about discussing it, something was shifting, notwithstanding the pandemic. 

According to the World Health Organization, the global prevalence of anxiety and depression increased by 25% in the first year of the COVID-19 pandemic. There was also an increase in substance abuse issues with 99,000 people dying from drug overdoses in the first full year of the pandemic in the United States, a nearly 30% increase from the year before. Even cigarette sales grew for the first 10 months of 2020, after an annual decline of between 4% and 5% since 2015.  

What specifically caused the mental health crisis to worsen? And what does the future of mental healthcare look like as we emerge from the pandemic?  

Loneliness and isolation

There are many potential causes for worsening mental health statistics, including stress, fear, and anxiety brought on by the virus; around 45% of people were found to have at least some fear of the virus, specifically among females, younger adults, urban residents, divorcees, healthcare workers, those in quarantine settings, those in suspicion of being infected, and, most notably, those with preexisting mental health problems. For those already suffering, COVID only made it worse. 

There’s also the grief brought on by a virus that killed over one million people in the U.S. alone; 40% of Americans know at least one person who died from COVID and there’s no way that much death and loss didn’t affect our nation’s psyche. 

The aspect of the pandemic that stands above all else when it comes to mental health problems is the loneliness and isolation brought on by the very policies put in place to protect people; namely lockdowns, school closures, and the move toward working from home. 

“Loneliness and increased individual and general societal disconnect are undoubtedly leading to more emotional duress. While rates of depression, anxiety, and suicide were, unfortunately, increasing before the COVID pandemic, the past few years have even further exacerbated the decline of our mental health,” said Mark Frank, co-founder and CEO of SonderMind, a digital behavoiral health and telehealth company.

“The pandemic increased our understanding of how important mental health is to people’s overall health, with anxiety and depression as two of the biggest challenges. We saw it in our children, our coworkers, our extended family members, and in ourselves.”

The pandemic response caused a lack of stability in people’s routines, said Russ Glass, CEO of digital mental health and wellbeing platform Headspace Health; he specifically pointed to how that isolation is affecting how people do their jobs. 

“Even now, when, ideally, we were hopefully starting to see the pandemic wane a little bit from the physical symptoms, the risk of the pandemic has gone down, we still don't know if we’re going back to the office. Are some people going to back offices and some not? There's evidence to suggest that those who do go back to the office are going to be promoted and have better long term outcomes than those who aren't,” he said. 

A survey conducted by Headspace found a third of employees saying work harms their mental health, something that Glass called, “a staggering fact.” In fact, 50% of Millennials said that they were considering leaving their job due to mental health issues.

“The workplace has become a center of mental health issues. I'm not saying that that didn't exist pre-pandemic but the pandemic accelerated that because you don't have the community you used to have, you're not getting to know your fellow workers like you used to, and you don't have the stability that you used to have,” he said. 

Even though most people seem to like working from home, citing better work-life balance and productivity, that doesn’t mean that there aren’t still negative side effects from that decision.

Nicola Hemmings, Workplace Scientist at Koa Health, a digital mental healthcare provider, pointed out both the short-term effects of remote work, including increased isolation and stress, but also the long-term, including “a lack of networking opportunities, leading to reduced career progression, impacting our motivations and life goals.”

“Having a commute allowed us time and mental space for us to 'psychologically detach,’ or switch off, from our ‘work role’ and transition into our 'home role.' Having work equipment, such as laptops and monitors visible at home also makes it harder to switch off and transition from our work roles as they act as a visual cue of the working day. When working remotely we also miss out on the social cues of a busy office such as the reminder to go home when the surrounding desks clear and the lights go off,” she said.

“We also miss out on the much-needed social interactions - making a drink in the kitchen whilst checking in and asking about the weekend. These seemingly small moments can collectively have a large impact on our mental health.”

The effect of homeschooling on women and children 

There’s a code of conduct called the Birkenhead drill, probably better known as the “woman and children first” rule, in which they would be saved first during a life-threatening situation because they need help the most. The most famous example of this were the passengers getting on lifeboats in Titanic. 

During the COVID pandemic, though, it was women and children who suffered the most, mostly because of policies that closed down schools: the pandemic was officially declared on March 11. By March 25 all public school buildings were closed; in turn, children had to turn to online learning.

The isolation that adults felt while working from home was felt just as equally, or more, by these children: in 2021, more than a third of high school students reported they experienced poor mental health during the COVID-19 pandemic, and 44% reported they persistently felt sad or hopeless during the past year. 

There were even worse unintended consequences of keeping children at home, with increased reports of abuse: more than half of those same high school students reported they experienced emotional abuse from a parent or another adult, and 11% experienced physical abuse.

All of this just made those preexisting mental health issues among young people even worse, said Headspace’s Glass.

“Social media, the proliferation of mobile devices, the reduced amount of sleep that they're getting, has all added up to a higher incidence rate, and higher acuity rate, of mental health need. The pandemic then hit what was already increasing and accelerated it: social interaction, the social emotional learning that happens at school is so important during this period of time, and it largely went away,” he said.

Part of that social interaction, he explained, is that kids often learn a lot of behaviors from the grade above them, something that could not be done while learning at home.

“They learn what's normal, they learn behaviors, they learn how to act, and there was a break in that, so they're having to relearn all of these things and restart the engine. This was one of the hardest years that a lot of teachers have had, because they have a cohort of children that are coming back to school for the first time and don't have the continuity of learning that they had prior.”

Ram Duriseti, MD, PhD, Clinical Associate Professor at Stanford University Medical Center, is a critic of the school closure policy: he believes that schools should never have closed in the first place, or at least should have reopened quickly after they were closed. Indeed, early on, it was evident that children had extremely low risk of sickness or fatalities and they weren’t the main vectors of transmission. This science, however, was largely ignored.  

“The reality, even going back to 2020, is that by mid, or end of May, at the latest, it was pretty clear that schools could reopen safely. Yet, we saw what happened in many states: by the fall of 2020, in many states, schools opened without mitigations and there was no dramatic change in outcomes, as could be expected, because severe outcomes in children are just incredibly uncommon, statistically. There was no mass debilitating illness of teachers or children. Community spread dictates spread in schools and not vice versa.” he said.

“We knew very early on which kids were at elevated risk and, in some ways, it was quite interesting, because it wasn't the usual suspects: you would think that kids with cystic fibrosis, or certain other respiratory illnesses, asthma included, would be at risk of severe outcomes, but that is not at all what happened. Quite surprising, actually. Without going into all the clinical details, that was pretty clear early on.”

The effects of this so-called “lost year” for students is already being felt: on average, students were five months behind in mathematics and four months behind in reading by the end of the school year. That may even continue to impact them in the future, with data suggesting that students may earn up to $61,000 less over their lifetime, with an impact on the US economy of between $128 billion to $188 billion every year.

On top of school closings, older adults increasingly went to live back at home during this time: in 2020, an estimated 4.2 million adults aged 70 years or older were homebound compared with 1.6 million in 2019. Thos didn’t just impact the children themselves, but the rest of their families as well, most notably working mothers; between February 2020 to January 2022, 1.1 million women left the workforce, totaling 63 percent of all jobs lost during that period, as women quit their jobs to take care of their families.  

“The group that was really hit hard were working parents, and particularly working mothers. Some of the myths about how it works to be a working parent, particularly a working mother in the United States, were debunked when all of a sudden you’re trying to do your job and take care of your kids and be at home and homeschool, and all those other things,” said Harry Ritter, Founder and CEO of Alma, a membership-based network for mental health care providers to build and scale their practices.

“It's a shock to your identity and who you are, when you're forced to make these really foundational choices, and confront these gender norms that you thought we were maybe getting behind or getting passed as a society. All of a sudden it’s like, ‘oh, no, because you identify as the woman in this relationship, you're going to suddenly be the default caregiver.’ That was really deeply traumatic for a lot of people.”

All of these factors combined to cause major mental health problems for struggling families who now had less income than they did before, plus an increased number of family members who needed their help, said Andi Summerville, executive director of the Wyoming Association of Mental Health and Substance Abuse Center.

“A lot of times people don't give enough thought to those financial struggles: the loss of a job, schools being closed, and now the person has to figure out how to make that work with their employer, how big of an impact that really has on people,” she explained. 

“It's certainly a driving factor in the increase in use of illegal substances or controlled substances here in Wyoming, as well as the mental health factors. Our suicide rate went up by an additional nine deaths in the state over the previous year. So, I really think it's important to recognize how much the economic struggles are impacting people on the ground.”

Where do we go from here? 

Now that we can look back on the last two years and see some of the consequences of the pandemic and the policies that emerged from it, have we learned anything?

For Sondermind’s Frank, one of the lessons that should be taken from the last two years is that the mental and behavioral health system is still broken, and people are still lacking the care they need, despite the prevalence of mental health problems. 

“We have more work to do to provide people with the high-quality care they need, when they need it, as locally as possible, covered by their insurance, and focused on outcomes. We’ll only be effective in meeting mental health needs if we redesign the entire system,” he said.

“The problems associated with the mental and behavioral health system must be addressed by simultaneously working within the existing healthcare ecosystem and by creating a compelling offering for all constituents of that ecosystem, including insurance companies, medical doctors, hospitals, mental health centers, self-insured employers and the broader set of organizations who deliver quality healthcare services to patients.” 

When it comes to lessons learned from the pandemic response, though, Duriseti’s view is that we haven’t learned anything at all.

“In 2020, emergency department visits dropped by average 34% nationally; however, cardiovascular deaths increased by 13%. What does that mean? There were a lot of people who were either dying at home or dangerously delaying care. They were afraid, not seeking care, so stress may have contributed to it. Most people do not know that non-COVID dementia deaths increased likely because vulnerable people were isolated and cut off from what little activity or physical therapy they had,” he said.

“We know that isolation and lack of stimulation, especially for elderly people, leads to accelerated decline, and we did that: not the virus. While we're not engaging in mitigation measures as much, in some situations, we're still acting as if our policies dictate spread. So, I don't see lessons learned.”

Of course, there were also positive outcomes, including advances in technology, specifically digital health and telemedicine, which will help both patients and physicians in the long run, said Alma’s Ritter: what would have taken years to become mainstream are now here, so we can look forward to even more advances, including the use of the Metaverse for patient to interact with their clinician. 

“I'm not necessarily talking about the virtual reality concept, I'm talking about just the idea of online community spaces and online connections and how we experience community and connection in a virtual environment. That's just this insanely cool whitespace, where, for the last decade, we've had really interesting businesses and technologies that have been floating in the ether trying to find an application. Wow, all of a sudden, there's actually a place for them to go, there's a world to be built,” he said.

“I predict that mental health care will look very different 20 years from now, 10 years from now, even five years from now, than it did compared to the difference in 100 years ago. It doesn't look all that different from 100 years ago but it's going to look a heck of a lot different in a decade or two decades, as we suddenly have the opportunity to bring more of that technology and digital animation into the care experience itself.”

Headspace’s Glass also believes that the pandemic sped up the willingness to access digital online interventions. That’s why his vision for the future of mental health is more data, and personalization, which will get people the care they need.

“The future is highly personalized. It starts with prevention all the way: in school curriculum, where kids are learning about how to take care of their mental health, just like they think about physical education today and then it's going to be highly measurement based. We're going to get you to the right level of care, depending on the need,” he said.

“I'm wildly bullish. The proof is in the outcomes that we're seeing, and if you compare the outcomes to the costs, there's no reason it shouldn't go this direction, but for the complexity of the healthcare system, and the regulatory environment. That takes time, but we'll get there. We're heading in the right direction.”

(Image source: pxhere.com)