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Friday, February 16, 2024

Mental Health in the US is Suffering—Will It Go Back to Normal?

After a particularly devastating transport, Rosemary, an emergency medical technician who works in the Boston area, realized that she was struggling emotionally. She needed to talk to someone. That day, she and her paramedic partner had arrived at the house of an older man who had symptoms of Covid-19, and they needed to get him to the hospital immediately. It was early May, and, at that point in the pandemic, families were not permitted to visit patients at the hospital, nor could they accompany their relatives in an ambulance.

“So we realized that we had to tell his wife that she couldn’t come with us,” recalls Rosemary, who asked to be identified by only her first name. “And it came to be revealed that this couple had been married for over 60 years. It was just absolutely soul-crushing for us to realize that. We knew there was a good chance that, if we took him into the hospital, he wasn’t going to come back out. So we were in the position of having to tell this woman, ‘You need to say goodbye to your husband.’” Once they had arrived at the hospital and safely passed the patient on to the doctors and nurses there, Rosemary went to a deserted corner of the parking lot and cried. “That was very, very difficult,” she says. “That one almost broke me.”

Rosemary reached out to Project Parachute, an initiative run by the online therapy platform Eleos that provides free therapy for frontline health care workers. Since it was founded earlier this year to support health workers through the pandemic, Project Parachute has connected over 380 frontline workers to pro bono therapy. Rosemary, who has previously experienced depression and anxiety, met with a Project Parachute therapist for four sessions, “just to talk to him about things, get stuff off my chest,” she says.

Rosemary is just one of the many people who has experienced worsening mental health during the pandemic—an increase that officials at the World Health Organization warned about back in May, when they wrote that countries would “risk a massive increase in mental health conditions in the coming months” if they did not sharply increase investment in mental health services.

Recent data seem to show that the warning was warranted: According to survey results released by the Centers for Disease Control and Prevention on August 14, 30 percent of respondents reported symptoms of anxiety and/or depression, versus 11 percent during the same time period in 2019. (The CDC survey, which was conducted at the end of June, also reported that over 20 percent of essential workers seriously considered suicide that month.) KFF, a nonprofit that conducts a monthly tracking poll of health indicators, found in July that 53 percent of respondents indicated that pandemic-related stress had affected their mental health, up from 32 percent in March. Dawn Brown, director of community engagement at the National Alliance on Mental Illness, which runs the free NAMI HelpLine for people seeking support and information, writes that, between March and July, they’ve seen a 65 percent increase in calls. Some callers have preexisting mental health conditions and reached out because of concerns about accessing medication or treatment during a pandemic, she writes; others did not have anxiety or depression diagnoses but were beginning to experience symptoms.

Some experts have worried that these challenges will add up to a “second pandemic” of mental illness. Back in April, four registered nurses, two of whom are professors at the University of California, Los Angeles, published an article in the Journal of the American Psychiatric Nurses Association that invoked a wealth of evidence to argue that Covid-19 patients, their families, clinicians, and those suffering from fear and loneliness at home could end up with serious psychological issues. And in June, psychiatrist James Lake warned of such a second wave in Psychiatric Times and anticipated that, left untreated, the psychological effects of the Covid-19 pandemic could have serious consequences for years to come. “Our mental health system is not prepared to deal with what may become a global mental health pandemic,” he wrote.

Ronald Pies, professor emeritus of psychiatry at SUNY Upstate Medical University, is not quite convinced that we are seeing a second pandemic of mental health issues—after all, someone who reports a symptom or two of depression doesn’t necessarily meet the full diagnostic criteria for the disorder. But if someone is experiencing enough pandemic-related distress to meet a clinician’s threshold for a diagnosis, Pies thinks, they do in fact have a mental disorder. “If a person develops a condition that meets full diagnostic criteria for MDD [major depressive disorder] during the pandemic,” he writes in an email to WIRED, “then, in my view, they have MDD.”

Yet others, like Tamara Browne, a lecturer in health ethics at Deakin University in Australia, caution that Covid-19 isn’t necessarily sparking unprecedented rates of diagnosable mental health concerns, even if some people do express enough symptoms for a diagnosis. To the contrary, stress, fear, and sadness may be completely explicable reactions to difficult situations, not signs of a pathology. “If you’re bereaving someone who’s died from Covid, or you’re really anxious because you’re working in a health care setting with loads of Covid patients and it’s like fighting a war, if you’re stressed about having lost your job, or you’re sending your kids to school or a daycare and you don’t know how safe they are, or you’re trying to look after them full-time while also trying to do your job full-time, because your job doesn’t allow for childcare—all this seems like understandably stressful situations that will cause you to feel anxious and depressed,” she says. “It doesn’t strike me as a dysfunction.”

This difference of opinion represents a long-running debate among experts on mental health that has found new relevance in the pandemic. Is the prevalence of disorders like anxiety and depression actually on the rise as a result of Covid-19, or are clinicians just seeing short-term reactions to stressful conditions? Which side experts come down on has a lot to do with what they think matters most: Is it a person’s symptoms, or is it their situation?

For Browne and some others, symptoms alone are simply not enough. “The risk of the symptoms approach is that we tend to not look at the causes,” says Şerife Tekin, assistant professor of philosophy at the University of Texas at San Antonio and an expert in the philosophy of psychiatry. Looking at the causes of someone’s distress is crucial, she believes, because causes can be changed, or at least responded to, in order to provide relief. Someone who is feeling depressed because they haven’t been able to see their friends during the pandemic could find a lot of relief through engaging in more virtual events or forming a social bubble. Once the pandemic is over and they can move around freely, they may feel completely back to normal. “When it comes to helping these individuals, I’m assuming the goal of diagnosis is actually to help the patient, to help the individual who is suffering,” Tekin says. “Just looking at the symptoms may not really get us there. We may really have to engage and look at the causes.”

Jerome Wakefield, a professor at the NYU Silver School of Social Work, agrees that context must be a crucial consideration when making a psychiatric diagnosis. “If the environment doesn’t allow you to do what you're naturally designed to do, is that a disorder?” he asks. “Of course not. I mean, you’re designed to breathe. But if you’re underwater and can’t breathe, that doesn’t mean you have a disorder.” Just like a surfacing swimmer, someone struggling with the emotional consequences of the pandemic may find relief as soon as their situation changes. “Probably, when things go back to normal, this isn’t going to continue,” Wakefield says. “Your feelings will go back to normal.”

Pies, however, sees it differently. He points out that even a contingent response to a specific situation can constitute a major health concern. “Consider this scenario,” he writes. “An elderly hiker with stable but underlying heart disease has a heart attack when a 12-foot grizzly bear suddenly appears in front of him. This poor fellow may have had an ‘understandable’ or even a ‘predictable’ response to the bear—but a heart attack is a heart attack!”

The debate about whether or not causes of emotional distress should be taken into account when making a psychiatric diagnosis is not new. It raged in the pages of academic and mass media publications as the DSM-5—or, more formally, the Diagnostic and Statistical Manual of Mental Disorders, which guides clinicians in diagnosing every disorder—moved toward its ultimate publication in 2013. The previous edition had included a “bereavement exclusion” for major depressive disorder, which stipulated that a person could not be diagnosed with depression if they had experienced the death of a loved one in the past two months and were not experiencing severe symptoms, like suicidal ideation. Though bereavement is an emotionally intense experience, it does typically improve on its own as time passes—and extreme sadness is a normal reaction to a major loss.

But the American Psychiatric Association, which has published the DSM since its first edition, decided to remove the bereavement exclusion with the publication of the DSM-5 in 2013. “The argument put forward for that was, ‘Well, we want to be able to help people who are struggling with grief, and there is really no objective difference between the two experiences, because, if you just focus on the symptoms, they are very similar,’” Tekin says.

And from some perspectives, this argument does make good sense. Imagine, for example, a doctor who is trying to treat a purely physical problem like a cough. Their patient will likely find relief from their symptoms with cough drops or Robutussin, regardless of what is causing their cough. But even in the case of physical symptoms, context can still matter. Someone who is suffering from seasonal allergies could feel better simply by changing their environment —say, staying inside and turning on an air purifier—while someone who is coughing because they have Covid-19 may ultimately need to be rushed to a hospital.

Similarly, Tekin says, in the case of psychiatric conditions, “even if you very simplistically say they have the same symptoms, when you look at it, what causes someone’s symptoms is going to be extremely important in the therapeutic context.” Someone who is grieving a recent loss probably needs a very different sort of help from someone who is experiencing depression with no obvious cause.

If a therapist understands someone’s symptoms as the product of the death of a loved one or of Covid-induced isolation, rather than as a fundamental pathology, they may recommend a less aggressive form of treatment. “There may be a way short of medication—maybe some talk therapy just to make you feel like you have human contact—but short of more heavy-duty interventions that have side effects,” Wakefield says.

That’s not to say, of course, that medication only works in some circumstances, and therapy in others. Medication may help people who are responding to difficult circumstances, and talk therapy can do a great deal for those whose symptoms have no obvious causes. But focusing on causes does open treatment possibilities that might not otherwise have been available.

And Browne thinks there are societal risks to treating emotional responses to events like the pandemic as medical issues. “The bigger risk that I see with medicalizing things when we may not need to, is that it places the problem in individualistic terms,” she says. “Anxiety and depression, especially in response to something like this global pandemic—those are not problems with you as an individual.” A person who has been suffering recently because of fear of contracting Covid-19, stress from its economic fallout, or anger over racial injustice in the wake of the killing of George Floyd is not feeling poorly because of factors specific to them. “The root cause is systemic,” Browne says.

Ideally, Browne believes, these sorts of systemic concerns should form the cornerstone of treatment. “Let’s look at the social things that we can do. Like, are they in bad housing—can we improve that? Have they just lost their job—can we help them with that?” she asks. Taken to its logical conclusion, this approach might demand radical political change. “Sometimes it’s just, ‘Well, I don’t know where the next meal is coming from.’” Browne says. “Maybe if we give people universal social security, that could help ease their worry about the next meal. Is it that, ‘Well, I’ve lost my health insurance now that I don't have a job?’ Well, what about universal health care?”

Tekin makes a similar point, pointing to a famous photo taken in May for The New York Times of the parking lot of the San Antonio Food Bank, crowded with the cars of people waiting for their turn to receive groceries. The economic fallout of the pandemic, she says, has “of course caused a lot of mental health challenges. But then the solution should not be, ‘Okay, let’s give all of these people who are waiting in the line some antidepressants and hope that they will feel better.’”

Wakefield agrees that psychiatric diagnoses can act as convenient distractors from fundamental socioeconomic issues—unjust systems can more easily be upheld if everyone who struggles under that system is seen as having an individual, internal problem. “We actually encourage mislabeling of negative emotions, because the negative emotions interfere with our hallowed task of producing and being efficient,” he says. If a person who is struggling with the demands of contemporary professional life is seen as mentally ill, the system can proceed just as before. But if that person is perceived as responding rationally to an untenable situation, it signifies that there may be something deeply wrong with our standard way of life.

That said, Wakefield, Browne, and Tekin agree that in the US psychiatric labeling is often necessary, since insurance companies will not cover any treatment—talk therapy, group therapy, or drugs—without a diagnosis. “It’s all very well for me in Australia to say, ‘Oh, you shouldn't have to get diagnosed with something to get treatment,’” Browne says. “But in the US, of course, you have to.”

And so, in the US at least, therapists must work within what some of them consider to be a flawed diagnostic system to make sure their patients get the care they need. “You have therapists who care more about helping people than they do about the niceties of the diagnostic system,” Wakefield says, “which is to their credit. And they diagnose with a DSM diagnosis, even if they don’t really believe it’s applicable.” As a result, rates of depression and anxiety during the pandemic could rise dramatically, even if therapists do not actually think that their clients have psychiatric disorders.

None of this is to say that there won’t be people—perhaps very many of them—who are experiencing new or worsening mental illnesses as a result of the pandemic. Frontline health care workers like Rosemary have experienced intense emotional pain, which could later spark into illnesses like post-traumatic stress disorder. “A lot of us have a lot of trauma from it,” Rosemary says. “And it can take quite a while for that to show.”

And even some people who have been struggling with the more humdrum dimensions of the pandemic—social isolation, worries about getting sick—may find that their distress doesn’t resolve when the pandemic does. “If somebody is enduringly and fairly deeply miserable, even if it’s not strictly speaking a disorder, there is a rate of transformation of that into a chronic disorder that doesn’t go away when the circumstances change,” Wakefield says.

But even those people who do develop more serious mental health issues may have something to gain from focusing on the causes of their emotional distress. “Someone who thinks, ‘Well, I’m really depressed, I can’t get out of bed, this is completely biological, I have no control over this, I can’t change the way I feel,’” Tekin says, may fail to make changes in their life that could improve their emotional well-being. “My self-narrative about my illness might affect my response,” she says.

Different narratives, then, may provide more paths toward improved emotional health. A person who places their experience in context, for example, can look to how others have overcome similar situations in the past. After all, this is far from the first pandemic. “Things like this have happened before. Let’s look at what happened, how people responded to that, and what we can do to make our response more effective,” Tekin says.

We are now eight months into the worst public health crisis that almost everyone alive has ever faced. In the US alone, over 6 million people have been infected with Covid-19, and about 180,000 have died. As of early August, the US unemployment rate stood at over 10 percent. Protests have erupted in the wake of yet another police shooting of an unarmed Black man, Jacob Blake. At the same time, Californians are now contending with record-breaking wildfires, Iowans are dealing with the aftermath of a destructive derecho storm, and Hurricane Laura recently hit the Gulf Coast. Even for those who may find psychological relief once the pandemic is passed, that relief doesn’t seem to be coming anytime soon. For now, Browne believes, the most important thing is to ensure that anyone struggling with their mental health has access to whatever resources might help them. “I don’t think that we should need to classify something as a mental illness,” she says, “in order for that suffering to be taken seriously and addressed.”

For Rosemary, now that the pace of Covid-19 ambulance calls in Massachusetts has declined, things are easier. But during the most intense period of the pandemic in the Northeast, it was access to therapy that made all the difference. Project Parachute is “a great resource,” she says. I can’t shout from the rooftops enough. It’s probably literally life-saving.”

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