At the beginning of May, blogs and Twitter and Facebook and all other types of social media were flooded with comments about this being mental health month. In years past in May, in my different jobs, I either attended, organized or participated in various educational forums held to commemorate May’s role as the month dedicated to raising mental health awareness.
As we reach the end of the month, I have to say that May 2020 is Mental Health Month to the Nth degree, as it falls smack in the middle of the COVID 19 pandemic.
In pandemics past, was there talk of the toll on one’s psyche? During the 1918 influenza pandemic, which, along with its twin tragedy World War 1, claimed millions of lives. It was in that era that the phrase “shell shock” was coined, a concept which preceded the diagnosis that we now know as PTSD. While the term originally corresponded only to the mental health syndrome experienced by soldiers exposed to the horrors of battle, in the 21st century there is wide spread recognition that any catastrophic event outside the realm of every day experience can set an individual up for PTSD. Rape, beatings, motor vehicle accidents, earthquakes---any severe, horrific event can lead to the development of PTSD.
Certainly, there are those who would argue that COVID 19 is one such event. The casualties Inflicted by this enemy go far beyond the immediate physical ravages of the virus on the respiratory and other organ systems. Symptoms consistent with PTSD are emerging among front line workers, including the suicide of a prominent ER physician in Manhattan whose hospital was treating high numbers of patients afflicted with COVID 19. Symptoms of PTSD include difficulty sleeping, an inability to shut off one’s mind, intrusive thoughts, hypervigilance, nightmares and detachment. We know that high levels of stress correspond with the body producing high levels of cortisol, the stress hormone, which, in turn, is associated with increased depression and a host of other symptoms.
It is not just frontline workers in COVID combat who are suffering. Reports of domestic abuse have skyrocketed as family members are forced to shelter in place with their abusers. Alcohol sales are up, and alcohol is often associated with abuse. Tens of millions have lost their jobs due to the economic fallout from this infectious catastrophe, and people who never thought this could happen to them are lining up at food pantries in order to feed their families. The hopelessness and despair that follow financial ruin are epidemic as well. If ever a country were ripe for an epidemic of depression, anxiety and alcoholism, to follow on the heels of SARS-CoV-2, it is the USA. We have 4% of the world’s population but 30% if its COVID 19 cases. Let that sink in for a moment.
In the early days of the shelter in place orders, I greatly expanded my practice of telepsychiatry to accommodate those patients adhering to strict stay-at-home guidelines. Curiously, early on, many of my patients were actually experiencing a reduction in mental health symptoms. My patients who had panic disorder with agoraphobia were feeling less anxious, because they were no longer feeling the pressure to leave their homes. All the practices which make them feel safe—grocery delivery, take out, avoiding crowds and public places—are now mainstream. My OCD patients said that they felt vindicated, because the practices they have been pursuing for years are now acceptable. Several of my patients who have schizophrenia were also feeling less stress, because case managers, family members, psychiatrists and therapists, all well-meaning, were no longer pressuring them to engage in social activity that they found anathema. It is now cool to be isolated.
As time has gone on, however, and as the duration of shelter in place orders slipped from days to weeks and into months, another group of people has become highly symptomatic. I observed in my own practice, and heard from colleagues, that people who had recovered from depression have had relapses. Others, on the other hand, are seeking out mental health help for the first time, people who had never imagined that they would be seeking help from a mental health professional.
As it turns out, these anecdotal observations are consistent with data gathered from large health care systems. An article published in the May 26, 2020 Wall Street Journal, quoting data from health research firm IQVIA, indicates that prescriptions for anti-anxiety medications such as Klonopin and Ativan rose by 10.2% in the U.S. to 9.7 million prescriptions in March 2020 versus 8.8 million prescriptions in March 2019. Prescriptions for anti-depressants such as Prozac and Lexapro rose 9.2% from 27.2 million prescriptions in March 2019 to 29.7 million prescriptions in March 2020. That same Wall Street Journal article said that another company, Express Scripts, reported that prescriptions for anti-anxiety medications rose 34% between mid-February and mid-March 2020.
That is an astonishing figure. Then again, it is not surprising. There has never been in our life times anything like this. On the one hand, there is the existential threat to existence posed by this microscopic organism called SARS-CoV-2. Then, there has been the cataclysmic economic collapse precipitated by efforts to deal with the pandemic. Perhaps worst of all, for most humans, who are pack animals, has been social isolation.
"There are, of course, the age-old adages dispensed to us by our grandmothers: get enough sleep, get proper nutrition, get enough exercise, all of which are now backed by science. "
Prior to this, in many studies over the years, one of the biggest predictors of illness has been the degree to which one has social connections. People who live in rural areas have shorter life expectancies and higher deaths by suicide than people in urban areas. Married men live longer than single men. People who are active in their chosen religion—regardless of what faith it happens to be—have better physical and mental health, and live longer, than people who have no identified spiritual affiliation. The common denominator in all this, the common protective factor, is social connectedness. Take away that connectedness and you have millions at risk for depression and anxiety. So we already see early evidence of increased mood disorders. Whether this results in large scale on increased rates of suicide remain to be seen.
The great irony of COVID 19 is that it spreads and kills through social contact, but the strict limitations on that social contact may be ushering in a second epidemic of depression.
As always, with my bias towards public health, I believe that prevention is better than treatment.
Big pharmaceutical companies and wealthy nations are rushing to develop a vaccine against SARS-CoV-2. That is likely a couple of years away. There are certainly those who are denying any risk to themselves and others and are thwarting social distancing recommendations. What about the rest of us, though, who may be in high risk groups ourselves, living with others who are at high risk, or who are civic minded and just trying to do what we think is prudent? Assuming that many of us will be engaging in some sort of social distancing for the next 18 to 24 months, what can we do to inoculate ourselves against depression and anxiety that are consorts of COVID 19?
There are, of course, the age-old adages dispensed to us by our grandmothers: get enough sleep, get proper nutrition, get enough exercise, all of which are now backed by science.
But keeping some level of social engagement also seems critical. Depending on your risk tolerance (which may be dependent on your age and underlying health conditions, or the age and health conditions of those with whom you live), you may choose to don a mask and go for a socially distant walk with a friend. Or have cocktails or coffee 6 feet apart in a driveway.
Others who are in isolated parts of the country which have yet to be infiltrated by the virus may feel comfortable with greater levels of contact. Then there are those who choose to interact only by Zoom, or Facetime, or What’s App, or whatever the video platform of your choice is. Or, depending on your WiFi access and tech savviness, you may be interacting only by phone.
The point, though, is to have interactions with others. Meaningful, socially invigorating interactions with others, not just the Zoom call with your work team to discuss this day’s or week’s projects. Not just time spent tweeting, re-tweeting or posting.
Make a point of connecting friends. Maybe set up a phone tree with a group of friends, so that everyone has someone checking in with them every day. There are others who need contact, too. It might help with your own mood and anxiety levels if you can reach out and help someone else. Maybe your church, or mosque, or synagogue or local senior center has a list of older adults who are living alone and shut in. Perhaps you could volunteer to call one or 2 of them. Or join—or set up—an online play group for parents of youngsters stuck at home. Zoom rooms with kids on one call, Zoom rooms with moms or dads on the other.
We need purpose, and we need each other. That is what makes us human. So as May is Mental Health Month 2020 draws to a close, I hope that we can carry that awareness into the second half of this outrageous year, and as we avoid infection, I hope that we can find creative ways of connecting to inoculate ourselves from perhaps an equally awful epidemic of depression.