Over the last year, perhaps you have observed yourself or those around you regularly experiencing what seems to be some version of low-grade depression. This feeling, characterized by insomnia, fatigue, poor concentration, and feelings of hopelessness, is among the innumerable and profound changes to life, and mental health specifically, that have arisen over the past 12 months. We’re unsure of how much longer the isolation and tedium of the pandemic will last and in what ways it will continue to have both an immediate and enduring impact on our mental health. Will your decreased ability to find pleasure in the things you used to enjoy be resolved when the pandemic abates? Is Zoom fatigue here to stay? In order to adequately care for our mental health in the present and in the years to come, it is essential that we better understand the potential long-term mental health consequences of the COVID-19 pandemic.
The preliminary research on the psychological toll of the pandemic, albeit limited in its depth, provides valuable insight into what it means for us to feel the way we do during COVID-19. One such study, published in the Journal of American Medical Association and led by Dr. Jianbao Lai from the Zhejiang University Medical School in Hangzhou, China, studied the intense psychological burdens experienced by healthcare workers directly working with COVID-19 patients [1]. They used the Generalized Anxiety Disorder Scale that defines severity on a scale of one to ten, with scores five to ten being moderate to severe anxiety, alongside a questionnaire about the general health of participants to determine the severity of the workers’ anxiety and depression. These scales asked a variety of questions reflective of an individual’s mental health in order to diagnose the severity of their condition. The study found significant prevalence of anxiety and depression in the 1,257 healthcare workers surveyed and that these rates were increasing compared to pre-pandemic rates, with an average score on the Generalized Anxiety Disorder Scale to be five [2].
In June of 2020, the Centers for Disease Control and Prevention (CDC) also conducted a survey of adults in the United States, finding that 40.9% reported psychological distress of some sort and that 30.9% had experienced symptoms of an anxiety disorder or depressive disorder during the past 30 days. According to data from this survey, the prevalence of depression has increased by about four times from the rate reported in the second quarter of 2019 (24.3% versus 6.5% of all adults), with anxiety disorders increasing by approximately three times (increase rate of 25.5% versus an increase rate of 8.1%) [2]. Perhaps most notable here is that this increase in mental health disorders since 2019 correlates to the timing of the pandemic.
Another survey that elucidates possible trends in mental health in the wake of significant events similar to the COVID-19 pandemic, is a study examining the effects of events concerning loss and danger in adolescents as well as their respective mental health repercussions [3]. This study, led by Dr. Eva Asselmann at the Institute of Clinical Psychology and Psychotherapy, Technische Universität in Dresden, Germany, found that traumatic events, defined as life events relating to significant loss or danger, often predicted incident anxiety or incident depression. Incident anxiety and depression are similar to General Anxiety Disorder and Major Depressive Disorder, respectively, in that they are categorized by consistent anxious sentiment and behavior in the case of anxiety, and feelings of hopelessness and fatigue in the case of depression, but are caused or catalyzed by a specific incident, hence the term incident depression and incident anxiety [3, 4, 5]. These events were categorized using the Munich Event List (MEL), a system that categorizes events of loss and danger on a scale from one to six [3]. Events varied in severity with six being the most intense; examples of these events range from enduring tension with parents (2.9), to continuous financial trouble (3.6), to sickness of a loved one (3.55), to death of a loved one (4.95), and to the death of a partner or child specifically (5.8). Notably, each of these traumatic events has been occurring on a more frequent basis during the COVID-19 pandemic. The study found that events centered around loss--for example, the death of a loved one--typically resulted in incident depression, whereas events that were categorized as related to danger--such as tension at home or financial trouble--resulted in both incident anxiety and depression [4]. If the social effects of COVID-19 can be defined as traumatic, similar to those defined in the study, then these findings indicate that the pandemic could cause increased rates of incident depression and anxiety in adolescents [4].
There are numerous types of mental illnesses that could increase in prevalence during and after the pandemic. Both incident depression and anxiety are plausible responses to distress, but a specific version of depression, called low-grade depression, is also a possible outcome. Low-grade depression, or dysthymia, differs from Major Depressive Disorder; the symptoms of Major Depressive Disorder include loss of interest and pleasure in activities as well as more intense and constant iterations of many of the symptoms that are associated with low-grade depression. Low-grade depression is a milder mood disorder, and its symptoms of general fatigue and hopelessness have been on the rise during the COVID-19 pandemic [2]. Incident depression is another variation of a depressive disorder relevant to changes in emotional state, which many are experiencing during the pandemic, as a type of depression associated with a specific event or time [3].
To illustrate these variations, mental health is currently screened using multi-question surveys that ask about a variety of aspects regarding the participant’s mental state and general sense of well-being. Someone with incident depression may go through two screenings for depression without being diagnosed, only to be diagnosed in subsequent screenings [5]. Someone with low-grade depression, on the other hand, would be diagnosed with low-grade depression at each screening [6]. The distinction between these variations of depression brings about a variety of questions: Could the symptoms of what seems to be low-grade depression, brought on by the pandemic, be defined more distinctly as incident depression? And if so, does this make it any easier to predict its occurrence or to treat its long-term outcomes?
Perhaps what’s most encouraging about Dr. Asselman’s survey is that it demonstrates lower instances of incident depression and anxiety seen in individuals who have had more time after the traumatic event and higher instances in those for whom little time has passed since the event. The individuals in the survey, whether they experienced loss in the death of a loved one or the stress of tension at home, were found to experience fewer symptoms of incident depression and anxiety as the years passed, with almost no participants reporting incident anxiety or depression after 10 years [4]. The pandemic has not left yet, and likely will not leave us for some time—but despite the way it may change us now, past and current studies related to the sort of emotional intensity and mental health experiences of the pandemic indicate that these changes may lessen with time and someday be less permanent than they now seem.
While the finding that incident depression and anxiety tend to heal with time is reassuring by some measures, it prompts further questions as to what can be done to address these issues of mental health both now and in the future [4]. The finding that incident depression and anxiety lessened over time did not specify if patients who experienced gradual decreases in incident depression sought out therapy or other services to help them process the events that precipitated their depression and anxiety [4]. Healing from trauma inevitably takes time, though there are steps that can be taken to help recover from these events. Antidepressants, for example, can help individuals suffering from depression or trauma to better cope with their experiences; chronic depression has been successfully treated by a combination of medication and therapy, and generalized anxiety disorder has been successfully treated with medication alone [3]. Whether or not individuals who experienced some version of depression due to the COVID-19 pandemic will seek out pharmacological treatment or therapy of any sort for their symptoms may depend on how long the pandemic lasts and whether their symptoms continue after the pandemic has ended.
Certain measures have been taken to address these mental health issues in the present rather than waiting until after the pandemic has ended. In the United States, the CARES Act (Coronavirus Aid, Relief, and Economic Security Act), passed in March 2020, included funding for mental health and substance abuse aid. Much of this funding was to the Substance Abuse and Mental Health Service Administration, where it was further distributed to a variety of causes, such as Certified Community Behavioral Health Clinics and suicide prevention programs [7]. The CARES Act also expanded coverage for Telehealth provided by Medicare, private insurance, and federally-funded programs.
These advances, however, do not mean that there are not still barriers and additional costs to mental health services for those who need them, even for those with insurance. A more comprehensive measure to ensure access to mental health resources, such as therapy or psychological evaluations, would require a more intensive act that addresses the issues of access to healthcare in general, and specifically mental healthcare, in the U.S. In its current guide to handling mental health during the pandemic, the CDC notes the importance of seeking help when needed, and recommends the following: “If distress impacts activities of your daily life for several days or weeks, talk to a clergy member, counselor, or doctor, or contact the SAMHSA helpline at 1-800-985-5990” [6]. Helplines can be an excellent resource for immediate help in mental health crises, but in terms of long-term help, the treatment an individual needs depends on what they have experienced.
Understanding which specific emotional changes one is experiencing during the COVID-19 pandemic is essential to understanding how to best treat ourselves and those around us as we move through, and beyond, this time. Looking at the preliminary research as well as past precedents, one can feel hopeful that the toll of such extensive isolation and change will perhaps not be as permanent as it may feel now. Steps have been taken on a national level to address these issues to a certain extent. However, further funding is necessary to fully address the mental health issues precipitated by what has already been a time of immense loss and loneliness for many, and for what will be an undoubtedly complicated aftermath. Optimism can be found in the knowledge that not only does time often heal the wounds of incident depression and anxiety, but therapy and medication can often successfully treat low-grade depression, as well as a variety of other mental illnesses that have been aggravated by the COVID-19 pandemic. Making these treatments accessible to all must be prioritized both now and in the years to come. In the meantime, an awareness of your own mental health and the mental health of those close to you may be helpful as we begin to grapple with just how deeply we have been changed by the COVID-19 pandemic.
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. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. MMWR Morbidity and Mortality Weekly Rep, 69(32), 1049–1057. http://dx.doi.org/10.15585/mmwr.mm6932a1
Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., Wu, J., Du, H., Chen, T., Li, R., Tan, H., Kang, L., Yao, L., Huang, M., Wang, H., Wang, G., Liu, Z., & Hu, S. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3). https://doi.org/10.1001/jamanetworkopen.2020.3976
Asselmann, E., Wittchen, H. U., Lieb, R., Höfler, M., & Beesdo-Baum, K. (2015). Danger and loss events and the incidence of anxiety and depressive disorders: a prospective-longitudinal community study of adolescents and young adults. Psychological Medicine, 45(1), 153–163. https://doi.org/10.1017/S0033291714001160
Crits-Christoph, P., Newman, M. G., Rickels, K., Gallop, R., Gibbons, M. B. C., Hamilton, J. L., Ring-Kurtz, S., & Pastva, A. M. (2011). Combined medication and cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 25(8), 1087–1094. https://doi.org/10.1016/j.janxdis.2011.07.007
Johns Hopkins Medicine. (2021). Dysthymia. https://www.hopkinsmedicine.org/health/conditions-and-diseases/dysthymia#:~:text=Key%20points,chemical%20imbalances%20in%20the%20brain
Centers for Disease Control and Prevention. (2019, September 13). Taking care of your emotional health. https://emergency.cdc.gov/coping/selfcare.asp
National Alliance on Mental Illness. (2020, March 27). Information on the CARES Act for people with mental illness. https://www.nami.org/About-NAMI/NAMI-News/2020/Information-
on-the-CARES-Act-for-People-with-Mental-Illness