Depression, anxiety may be side effects as nation grapples with COVID-19

Millions of Americans are being impacted by the psychological fallout from the COVID-19 pandemic and its economic aftermath, and large numbers may experience emotional distress and be at increased risk of developing psychiatric disorders such as depression and anxiety, according to a new article published this week in the New England Journal of Medicine.

The Perspective article, co-authored by Carol North, M.D., a UT Southwestern crisis psychiatrist who has studied survivors of disasters including the 9/11 terrorist attacks and Hurricane Katrina, calls on already stretched health care providers to monitor the psychosocial needs of their patients as well as themselves and fellow health care workers during this time.

"Almost everyone may experience some distress - some more than others," says North, a member of UT Southwestern's Peter O'Donnell Jr. Brain Institute who wrote the article with first author Betty Pfefferbaum, M.D., a psychiatrist at the University of Oklahoma College of Medicine. While conditions arising from a naturally occurring pandemic do not meet the criteria for trauma required to diagnose post-traumatic stress disorder (PTSD), depression and anxiety may result from this pandemic, according to the article, and some people may even become suicidal.?

Shortages of resources needed to treat patients, uncertain prognoses, and public health measures such as shelter-in-place orders - along with the resulting financial upheaval - are among the "major stressors that undoubtedly will contribute to widespread emotional distress and increased risk for psychiatric illness associated with COVID-19," the article says.

Certain groups will be more highly affected, according to the paper. That includes people who contract the disease, those at heightened risk including the elderly and people living with underlying health conditions, and those with preexisting psychiatric or substance abuse problems.

Health care providers are also especially vulnerable to emotional distress during the pandemic, the paper continues, given their risk of exposure amid shortages of personal protective equipment, long work hours, and involvement in the "emotionally and ethically fraught" need to allocate scarce resources when treating patients.

A recent review of the effects on quarantined people and health care providers in earlier disease outbreaks found stress, depression, insomnia, fear, anger, and boredom, among other problems, the article says.

While not directly comparable, many who went through other catastrophic events such as 9/11 or 1995's Oklahoma City bombings developed depression as well as PTSD, says North. After 9/11, 26 percent of the attack's survivors developed a new episode of major depression, according to an earlier study she co-authored. But COVID-19 is new territory, she emphasizes. "We haven't studied depression in pandemics."

The pandemic is creating a multilayered disaster, North says.

"There is the fear of being exposed and getting sick and dying, as well as loss of the lives of friends and relatives. Then there are secondary effects - lost paychecks and the economic woes. Rates of suicide go up in populations when economic times get bad. People get stressed more in general when times are bad," she says.

First responders and health care professionals should be trained to evaluate the psychosocial issues surrounding COVID-19, the report says, and health care systems need to pay attention to the stress level of their workers and alter assignments and schedules if needed.

Health care workers should ask patients about COVID-19-related stress factors, such as an infected family member and any depression or anxiety, and also check for vulnerabilities like a preexisting psychological condition. While some patients will need a referral for mental health care, others may benefit simply from support to improve their ability to cope.

Providers can offer suggestions for stress management. Because parents often underestimate their children's distress, they should be encouraged to have open discussions to address their children's reactions and concerns, the report adds.

People in quarantine or sheltering at home should try to reach out to loved ones electronically, North says. "People are now communicating more with loved ones and friends than they did before this crisis. For example, I did a Zoom meeting with my siblings recently for the first time. It was very nice."

Maintaining a schedule helps as well, she says: "Get up. Have breakfast. Get dressed."

And avoid following the COVID-19 news if that adds to stress, North says.

"Most people are resilient. Most people don't develop psychiatric illness after even horrible things, and most people who develop psychiatric illness can recover," she says. "After 9/11, only a third of the people directly exposed developed PTSD (35 percent in her study)."

Betty Pfefferbaum, Carol S North.
Mental Health and the Covid-19 Pandemic.
NEJM, 2020. doi: 10.1056/NEJMp2008017

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