In Pandemic’s Wake, A Toll on Mental Health — and Some New Approaches

This blog post highlighting Episodes 58 and 59 of the Epidemic podcast is sponsored by RubiconMD.

“[The pandemic] is not like a lot of the other disasters that people have studied” with respect to mental health, says Dr. Roy Perlis, a psychiatry professor at Harvard Medical School, on Episode 59 of EPIDEMIC. “This is a much more chronic stress. It looks a lot more like what you’d expect to see in people who have lived through a war.”

While its destruction has been quieter, and its havoc more hidden, the pandemic’s loss of life, shattering of routines, and suspension of support systems have in some ways taken a war-like toll. Average life expectancy in the United States has dropped by nearly two years as a result of COVID. This is due not only to deaths from the virus itself, but to other hardships wrought by the pandemic — from difficulty accessing healthcare in overwhelmed medical systems; to poor handling of chronic health conditions; to the pandemic’s strains on mental health, with increased rates of depression, anxiety, and suicide. 

“This is sort of a perfect storm where you have more forces pushing people towards depression,” says Perlis. “You have that … chronic stress plus the acute stress of either getting sick or having a loss.”

As COVID infection and mortality rates decline in many parts of the country, some of the pandemic’s roiling of mental health will linger. In its wake, the pandemic leaves spikes in depression, anxiety, and overdoses — along with some new approaches to treatment, with a rise in telemedicine and a keener awareness of health inequities laid bare by COVID’s skewed path.

What have been the mental-health effects of the pandemic on youth and adults? 

On Episode 59, Perlis reports that depression, anxiety, and suicidal thinking have all increased since the beginning of the pandemic, especially among younger Americans. Perlis is a Principal Investigator for the COVID States Project, a national Internet-based survey that gathers the experiences of about 20,000 people per month. Up to one-third of the 18-to-24-year-olds in Perlis’s study have reported suicidal thoughts during the pandemic — rates of suicidal thinking that are 5 to 10 times higher than normal. 

Perlis notes the loss of structural support for this group in the past year, with many high schools and colleges in virtual-learning mode. “For a lot of [young adults], their first contact with any sort of mental-health care is wandering into student health and talking to someone,” says Perlis. “And that’s a lot harder to do when you’re going to school on Zoom.”

While older adults seem to have fared better in terms of mental health, this spike in depression and suicidal thoughts crossed divisions of race, gender, and even political affiliation. 

How has economic distress impacted mental health?

Perlis has noticed startling correlations between depression and economic stress in his monthly COVID surveys. “One of the things that has been most striking to me as a psychiatrist is realizing how much of the depression we’re seeing is driven by economics,” he says. “You’re about 20 percent more likely to have symptoms of depression if… you’re behind on your rent. You’re more than 20 percent more likely to have depressive symptoms if … you’ve been evicted. About 10 to 15 percent more likely to tell us that you’re depressed if you’ve had to cut down on your work, because your hours were reduced or your wages were reduced.” 

College education correlates with a substantial boost in income: Today, those with college degrees make, on average, 80 percent more than those without. In recent decades, says Anne Case, an economist and professor at Princeton University, the United States has seen a “ratcheting downward” of the number of people employed relative to the population, and a long-term downward trend in wages for those without a bachelor’s degree. Case explains that a history of tying health benefits to employment in the United States has made low-wage workers relatively “expensive” to hire. “Employers just decided, ‘We can do without those workers; we’ll just hire in from outsourcing companies,’” she says.

That decimation of the low-wage labor market means fewer jobs, of course; but it also translates to economic stress and a surge in what Case calls “deaths of despair” in the working class — from suicide, drug overdose, and alcoholism. And for many, the pandemic has amplified economic stress even as it’s put traditional forms of support off limits. Case describes the sense of helplessness and hopelessness that can fuel these “deaths of despair:” “It’s a lack of hope that there will be something in the long run coming for me, helping me and my family,” she says.

In the United States, employment, health insurance, and a college degree all work as protective factors against suicide. While many people with college degrees have been able to work from home in the pandemic, those working low-wage jobs — in grocery stores, public transportation, and restaurants, for instance — have often needed to continue working in-person, or have lost their jobs altogether. Often, this has meant increased financial stress and greater risk of exposure to COVID — compounding the vulnerabilities of a group already at greater risk.

How has the pandemic affected opioid and other drug overdose rates?

“Diseases and disasters … don’t create disparities and inequalities; they expose them,” says Dr. Will Cooke on Episode 58 of EPIDEMIC. Poverty, intergenerational trauma, systemic racism — all these were present before the pandemic. But economic turmoil, social isolation, and disruptions in access to care and community support systems amplified the effects of those inequities — and made many more vulnerable to addiction, with overdose rates spiking nationwide.

“When the pandemic hit, our recovery groups shut down,” says Cooke, whose book, Canary In The Coal Mine, focuses on the national response to the opioid epidemic and Cooke’s own experience as the only medical doctor in Austin, Indiana — a city caught in both the opioid crisis and a drug-fueled surge in HIV and hepatitis C transmission. Cooke developed a successful program to help those struggling with drug use; between 2015 and 2019, new HIV cases in Austin plummeted 95 percent. Then came the pandemic. And while many recovery groups went online, says Cooke, “that’s really not the same. All that great work that we had been building momentum towards — and really seeing amazing results — came to a screeching halt.”

The pandemic saw overdose-related emergency-room visits climb by 80 percent in Indiana, and overdose-related deaths jump by 20 percent. “So it’s been a dramatic impact,” says Cooke. He attributes a rise in relapse rates, in part, to the loss of community during COVID. “It’s when people start isolating that they are at the most risk for relapsing,” he says. “And we all basically had to isolate because of what was going on with the spread of COVID-19. ” As people lost support systems that had provided them with “hope, opportunity, community and recovery,” says Cooke, many turned back to opioids.

How has the mental health-care landscape changed during the pandemic? What can we learn from these changes?

“For most other wealthy countries, suicide rates have been falling,” says Case, the economist, on Episode 59. “So we stand alone in terms of seeing 158,000 Americans die in 2017 — and again in 2018 — from these deaths that no one should die from. That’s just not happening in other countries. But of course, also, in other countries, they fund their health-care systems differently.” 

While the pandemic has created immense psychological strain, mental health was a concern in the United States long before COVID. As Perlis says, “COVID just laid bare where the cracks were in our system. And the big crack in mental health is access.” 

That’s one realm in which the pandemic may have generated some welcome change. Since COVID hit, increased use of telemedicine has helped to diminish this barrier of access — at least for those with Internet access and a quiet space to talk.

“What we’ve learned is telemedicine really works,” says Perlis. “Patients embrace it; clinicians, including psychiatrists, really find it pretty effective.” Perlis says that at his hospital, no-show rates for psychiatry outpatient programs have decreased significantly, because joining an appointment via Zoom is typically easier than traveling to a doctor’s office. 

Not only has the pandemic demonstrated the efficacy of virtual mental-health services; many hear in its reverberations a clarion call for making health care accessible to all — financially as well as logistically. The pandemic has offered “an opportunity to think about real change,” says Case. “And that real change is going to mean unlocking health insurance from employers.”

“We really do have to get a handle on prices in the health-care industry,” she continues. “And if we don’t do that, then it’s still going to be this cancer on the U.S. economy and on low-wage people that’s going to continue to grow.”

Pandemic strains on mental health — with a year of social isolation layered on economic shock — have been chronic, widespread, and severe. However, the pandemic has also brought keener attention to a public-health landscape riven with inequities, and given a glimpse of what more technologically advanced and accessible mental-health care might look like. 

The next steps? Reforming mental-health care –– for good. 

“As a virtual-first specialty care platform, we believe that patient care plans include both physical health and mental health. Our Behavioral Health platform case submissions throughout the pandemic showed how mental health issues can exacerbate a patient’s care complexity if not treated properly from the beginning. This blog post shares the positive impact telehealth provides for mental health services and resources.” — Gil Addo, CEO/Co-founder of RubiconMD

About RubiconMD

RubiconMD is leading the mission to democratize medical expertise through its virtual-first specialty care solutions. The RubiconMD eConsult and Behavioral Health platforms remove barriers to specialty expertise by rapidly connecting primary care clinicians to a board-certified panel of experts. These solutions empower clinicians to deliver higher-quality care plans in a timely manner. RubiconMD eliminates unnecessary referrals and services, reduces patient wait times and travel burdens, and allows primary care to practice at the top of their license. With RubiconMD clinical teams can streamline their workflows, lower the cost of care, and deliver a better patient experience. For more information, please visit www.rubiconmd.com, or follow us RubiconMD on LinkedIn, Facebook, or Twitter.

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