More and more studies confirm widespread psychological fallout from the pandemic. The studies also confirm intuitive expectations about which populations are most psychologically vulnerable—those directly experiencing illness and death, those with economic hardship, frontline health care and other essential workers, and more.
But the published studies do not yet answer several critical questions. Do people having troubled emotional reactions to the pandemic have diagnosable mental disorders? Do increased rates of alcohol and drug use constitute a rise in the prevalence of diagnosable substance use disorders and addiction? How long lasting will emotional reactions to the pandemic be? Will they dissipate as the pandemic and the socio-economic conditions it has engendered come to an end? Will they last long beyond the pandemic itself, creating increased long-term need for behavioral health services?
What We Know
The studies confirm that some of the people experiencing emotional distress have pre-existing mental and/or substance use disorders that have recurred or been exacerbated during the pandemic. But they also make it clear that people, with and without diagnosable disorders, have experienced a broad range of emotional distress—including fears regarding illness and death, desperation regarding economic survival, isolation and loneliness, loss of a sense of control, hopelessness and profound sadness, moodiness, difficulties sleeping, family tensions, and grief.
The studies also indicate that reactions during the pandemic vary substantially. Some people are experiencing high levels of emotional distress; some very little. For some, emotional distress is relatively constant, for some it has declined and for some it has increased. For many people, emotional distress is “up and down.”
The Pulse survey done weekly by the Census Bureau initially showed a decline in emotional distress overall, suggesting some adaptation was taking place. Later, the survey indicated an increase in the number of people experiencing psychological distress, though this may also reflect political and racial tensions as well as the pandemic itself.
All of the studies show that some populations are experiencing more emotional distress than others, including:
- Those with direct experience of sickness or death due to COVID-19
- Those without adequate income, food, or housing
- Healthcare providers and other essential workers
- People of color
- People with pre-existing cognitive or behavioral disorders who are at risk for relapse or severe reactions
- Working parents with children at home
- Family caregivers.
The one finding that has been surprising to some people is that young adults are more at risk for emotional distress than older adults. But this should not be a surprise because, contrary to ageist perceptions, most older adults are not disabled and in need of help, and most have survived difficult times that have taught them to cope.
Nevertheless, many older adults experience significant emotional distress largely related to their vulnerability to illness and death and due to social isolation.
What We Do Not Know
The surveys unfortunately do not tell us whether reported emotional distress constitutes diagnosable mental or substance use disorders because diagnosing these conditions typically requires an interview or more in-depth questioning. The surveys are essentially screening tools rather than diagnostic instruments.
Whether or not they provide an adequate indication of diagnosable behavioral health conditions, they certainly do not answer the critical question of whether the psychological reactions to the pandemic will be long-lasting. After all, even some “serious” disorders, are transient, and some people will certainly experience adaptation and resilience over time.
In general, we do not know to what extent psychological reactions will diminish as the pandemic and its economic consequences diminish and to what extent there will be lingering emotional damage.
Implications for Behavioral Health Policy
Telehealth: Some behavioral health need is being met via tele-mental health. Unfortunately, many of the rule changes that support use of tele-health are temporary. They need to be made permanent. In addition, tele-health is not available to everyone due to lack of internet access, lack of needed hardware, and lack of technical skill. These issues need to be addressed.
Social Determinants: It is also essential to address the social determinants of emotional distress—economic hardship, persistent racial/ethnic inequities, the vitriolic political divide, and more. It is time for our society to face up to the social determinants of physical and behavioral health.
A Mental Health Tsunami? The claim made by some that there is a second pandemic coming—a tsunami of mental illness and substance abuse—is neither confirmed nor disconfirmed by existing studies. We do not know how long lasting and severe the lingering psychological effects of the pandemic will be.
Unmet Need: Whether or not there is a behavioral health tsunami, we know that our nation’s capacity to respond to behavioral health needs is woefully inadequate. We know that there are, and will continue to be, fault lines in American society that will continue to contribute to mental and substance use disorders if they are not addressed more effectively.
The pandemic has highlighted long-standing failures to meet America’s behavioral health challenges. It is long past time to act.
Michael B. Friedman taught at Columbia University School of Social Work before he retired. He is currently volunteer Chair, AARP Maryland Brain and Behavioral Health Advocacy Team. Calliope Holinque, MPH, PhD, is a postdoctoral research fellow at Kennedy Krieger Institute and the Johns Hopkins Bloomberg School of Public Health.
