“I’m in a constant state of fear.”
“I have nothing to look forward to now.”
“I don’t know when my life will go back to normal.”
As a psychiatrist practicing in a busy urban academic medical center, I have started to see the toll that the COVID-19 pandemic has taken on individuals’ mental health. Although some patients primarily worry about the virus itself, I have been more struck by the emotional distress associated with the shelter-in-place orders that have been enacted throughout much of the nation. With the potential for a “quarantine” to last many more weeks, if not months, we face the prospect of tackling a mental health crisis in addition to taming the coronavirus.
Few medical professionals question the necessity of social distancing and shelter-in-place orders to reduce the spread of the coronavirus and prevent hospitals from being overwhelmed. There has been comparatively less discussion of how prolonged social isolation will impact individuals’ emotional health. As much of the medical world rightly focuses on those with COVID-19 and those at risk for the infection, there is the potential for other patient populations to be overlooked.
Human beings are social creatures. Lack of regular human contact can be psychologically devastating. Those who experience significant social isolation are at greater risk for depression, anxiety, suicide, addictions, and a host of other mental health issues. For many, the injurious effects of social isolation will be exacerbated by other consequences of the pandemic, such as job insecurity and economic distress.
Despite the abundance of humorous memes about how some are using the “quarantine” to indulge in binge-watching and comfort food, many people are finding the experience anything but pleasant. Many are demoralized and frightened about the possibility of having minimal face-to-face social contact for months on end.
Depression and anxiety are two common reactions to catastrophic events, such as the COVID-19 pandemic. In this current crisis, depression, in many ways, represents a bereavement process. People are grieving the loss of things big (college graduation, family vacation, wedding) and small (happy hour, basketball games, trips to the mall) that now will never be or will not happen for a long time. For some, their outlook will become darker, believing that nothing good is happening in their life, or that there is nothing positive to look forward to.
Anxiety is often associated with uncertainty, and those more prone to anxiety have a greater intolerance of uncertainty. Very few individuals have experienced a situation more uncertain than this pandemic. Countless patients have told me that they can endure living in isolation for a few weeks, but they dread the prospect of being in a “lockdown” for months. There is palpable fear that life will not return to “normal” anytime soon, or that it will never do so at all.
At times I have been amazed by how some of my sickest patients have accepted this situation with grace, resilience, and humor. But I increasingly fear how patients with mental illness will cope with a “quarantine” that lasts into the latter half of 2020. Even the healthiest of individuals will find it difficult to tolerate social isolation for months on end. Those with mental illness will likely fare much worse.
Just as more of our patients are at increased risk for psychological problems, psychiatrists and other mental health treaters are impaired in our ability to optimally care for our patients. To minimize the risk of infection for both our patients and us, many psychiatrists have been conducting appointments via telemedicine — i.e., meeting with our patients via phone call or video call. We are fortunate that modern technology enables this, and patients are grateful for any means of maintaining contact with us. That said, no technology replaces face-to-face interaction, and much is lost when in-person interactions are translated to video. All patients value “in the flesh” meetings with their physicians, and this is even more true for patients with mental illness. Patients cherish these face-to-face contacts. Sadly, now they are much less available when patients need them most.
Other aspects of shelter-in-place orders impede physicians’ ability to effectively treat our patients with anxiety, depression, and similar ailments. A mainstay of managing mental illness is the use of behavioral interventions – changing the day-to-day habits and routines that shape our thoughts and feelings. Ironically, the types of behavioral interventions we consistently recommend to patients with mental illness — getting out of the home, exercising regularly, being socially active, planning pleasurable activities – are things that shelter-in-place orders forbid or make very difficult.
While premature relaxation of social distancing rules would be irresponsible, public health leaders must also explore how prolonged social isolation will imperil those with mental illness. Although a shelter-in-place policy lasting into the late summer or even autumn would undoubtedly reduce the spread of COVID-19, will it be worth the costs borne by those with mental illness? It is admittedly a challenge to weigh the varying needs of different patient populations, and no solution will be perfect. But the impact of these decisions on those with mental illness cannot be omitted from these discussions.
As the nation debates how to optimally manage COVID-19, there are things we can do now to protect our own and others’ mental health, both on an individual level and a societal level. Now more than ever, it is critical for all of us to stay in close contact with friends, family, and other social supports. For those with friends or family who are struggling emotionally, proactively reaching out to them can literally be a lifesaver.
While our government is devoting many resources to fighting the coronavirus, it must also commit to providing sufficient funding for mental health care.
This is true both now and going forward, as many psychiatric ailments that begin during the pandemic will persist as COVID-19 subsides. The government must ensure that health insurance companies cover mental health issues the same as they cover all other medical problems. This still does not happen consistently, despite mental health parity laws on the books. Despite its imperfections, telemedicine has been a lifeline for patients during this pandemic, and new regulations can help guarantee that health insurance companies pay for telemedicine visits.
The COVID-19 pandemic will be not one health care crisis, but many crises are occurring simultaneously. Our choices in the coming weeks and months will determine whether a surge in mental illness will be one of these crises.
Michael Ziffra is a psychiatrist.
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