It has been just over a year now since the coronavirus (COVID-19) pandemic struck the United States full force. A year of hunkering down and Zooming in, teleworking and telepsychiatry, economic and social upheaval, and steady scientific progress. Looking back to last March, we knew this would be difficult. But we didn’t know how difficult. And we certainly didn’t know that the challenge of COVID-19 would last this long.
This year has been a challenging one on multiple fronts. For many Americans, this challenge has been overwhelming, affecting their mental health. Understanding the impact of the pandemic on mental health, and on those with serious mental illness, is critical to the National Institute of Mental Health (NIMH) mission of responding with research that will pave the way for prevention, recovery, and cure.
From prior research on disasters and epidemics we mostly knew what to expect. In the immediate wake of a traumatic experience, large numbers of affected people report distress, including new or worsening symptoms of depression, anxiety, and insomnia. Most people will recover, though that recovery can take some time. A notable fraction of people will develop chronic symptoms severe enough to meet criteria for a mental illness, such as post-traumatic stress disorder (PTSD) or major depressive disorder. People who experience more severe stressors, such as exposure to the dead or dying, and people with more prolonged disruptions are more likely to experience enduring symptoms that would benefit from intervention. We also know that people are more likely to develop chronic or severe reactions if they have one or more risk factors, such as poor social supports, financial difficulties, food or housing instability, or a history of mental illness. Receiving economic or social supports and using coping strategies can lower these risks and maximize a person’s chances for recovery.
It seems that much of what we have learned from past disasters and epidemics is holding true in the context of the COVID-19 pandemic. Several surveys, including those collected by the Centers for Disease Control (CDC), have shown substantial increases in self-reported behavioral health symptoms. According to one CDC report, which surveyed adults across the U.S. in late June of 2020, 31% of respondents reported symptoms of anxiety or depression, 13% reported having started or increased substance use, 26% reported stress-related symptoms, and 11% reported having serious thoughts of suicide in the past 30 days. These numbers are nearly double the rates we would have expected before the pandemic. As in prior studies, this survey showed that risk factors for reporting anxiety symptoms or suicidal ideation included food insufficiency, financial concerns, and loneliness.
The CDC, NIMH, and numerous other government agencies and non-profit organizations have been spreading the message that physical distancing doesn’t mean we must stop supporting one another. In fact, research shows that helping others is a coping strategy that can reduce the mental health impacts of the pandemic. We also know that addressing people’s basic needs can help alleviate their psychiatric symptoms. For example, one study showed that food insufficiency was independently associated with all symptoms of poor mental health, but that association was mitigated for those who received free groceries or meals.
Early in the pandemic, there were concerns that suicide rates would increase. So far, data from the CDC suggest that overall suicide death rates have remained steady or have even fallen during the pandemic.
Yet, there is also cause for concern in the emerging data. There is clear evidence that the pandemic has not affected all Americans equally. As is often the case, unfortunately, the most vulnerable among us are also feeling the mental health effects most intensely. Job loss, housing instability, food insecurity, and other risk factors for poor outcomes have disproportionately hit minority communities. And while overall suicide rates may have remained steady, data from states such as Maryland and Connecticut suggest that, early in the pandemic, the number of African Americans dying by suicide increased.
Emerging data also indicate that people with schizophrenia and other serious mental illnesses have also been hard hit by the pandemic. Individuals with schizophrenia, for instance, are nearly 10 times more likely to contract COVID-19 and are nearly three times more likely to die from it if they do fall ill, compared with individuals who do not have a mental illness. Finally, deaths due to opioid overdose rose substantially in the context of the pandemic. These data remind us that we need to work hard to address long-standing disparities and ensure access to life-saving medical and psychiatric care is available for all Americans.
Indeed, the pandemic has raised awareness of mental health symptoms and service needs. Crisis intervention services such as SAMHSA’s Disaster Distress Helpline (1-800-985-5990) and the Crisis Text Line (text HOME to 741741) reported substantial increases in volume early in the pandemic, reflecting anxiety and distress brought on by COVID-19’s many uncertainties. And although data indicate the volume of mental health and suicide risk visits to emergency departments initially dropped when states issued stay-at-home orders, these visits increased again after stay-at-home restrictions were lifted.
The CDC, NIMH, and other agencies have been working hard to raise public awareness of the resources that are available to support people’s immediate mental health needs, including the Disaster Distress Helpline, the Crisis Text Line, and the Suicide Prevention Lifeline (1-800-273-TALK). In addition, many mental health care providers made a rapid transition to phone- and computer-based telehealth, with widespread adoption across both private and public mental health systems.
The mental health impacts of COVID-19 continue. From all that we know, it is clear these impacts will outlive the pandemic itself. Therefore, it is crucial that we work together to apply evidence-based strategies to support the mental health needs of all Americans and to make these strategies broadly available, especially in vulnerable communities.
Bray, M. J. C., Daneshvari, N. O., Radhakrishnan, I., Cubbage, J., Eagle, M., Southall, P., & Nestadt, P. S. (2020). Racial differences in statewide suicide mortality trends in Maryland during the coronavirus disease 2019 (COVID-19) pandemic. JAMA Psychiatry. http://dx.doi.org/10.1001/jamapsychiatry.2020.3938
Czeisler, M. É., Lane, R. I., Petrosky E., Wiley, J. F., Christensen, A., Njai, R., Weaver, M. D., Robbins, R., Facer-Childs, E. R., Barger, L. K., Czeisler, C. A., Howard, M. E., & Rajaratnam, S. M. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Morbidity Mortality Weekly Report (MMWR), 69, 1049–1057. http://dx.doi.org/10.15585/mmwr.mm6932a1external icon
Mason, M. Welch, S. B., Arunkumar, P., Post, L. A., & Feinglass, J. M. (2021). Opioid overdose deaths before, during, and after an 11-week COVID-19 stay-at-home order — Cook County, Illinois, January 1, 2018–October 6, 2020. MMWR Morbidity Mortality Weekly Report, 70, 362-363. http://dx.doi.org/10.15585/mmwr.mm7010a3
McKnight-Eily, L. R., Okoro, C. A., Strine, T. W., Verlenden, J., Hollis, N. D., Njai, R., Mitchell, E. W., Board, A., Puddy, R., & Thomas, C. (2021). Racial and ethnic disparities in the prevalence of stress and worry, mental health conditions, and increased substance use among adults during the COVID-19 pandemic — United States, April and May 2020. MMWR Morbidity Mortality Weekly Report,70, 162–166. http://dx.doi.org/10.15585/mmwr.mm7005a3external icon.
Mitchell, T. O., & Li, L. (2021). State-level data on suicide mortality during COVID-19 quarantine: Early evidence of a disproportionate impact on minorities. Psychiatry Research, 295. https://doi.org/10.1016/j.psychres.2020.113629.
Nagata, J. M., Ganson, K. T., Whittle, H. J., Chu, J., Harris, O. O., Tsai, A. C., Weiser, S. D. (2021). Food insufficiency and mental health in the U.S. during the COVID-19 pandemic. American Journal of Preventive Medicine. https://doi.org/10.1016/j.amepre.2020.12.004.
Nemani, K., Li, C., Olfson, M., Blessing, E. M., Razavian, N., Chen, J., Petkova, E., & Goff, D. C. (2021). Association of psychiatric disorders with mortality among patients with COVID-19. JAMA Psychiatry. http://dx.doi.org/10.1001/jamapsychiatry.2020.4442
Wang, Q., Xu, R., & Volkow, N. D. (2021). Increased risk of COVID-19 infection and mortality in people with mental disorders: Analysis from electronic health records in the United States. World Psychiatry. https://doi.org/10.1002/wps.20806