The Mental Weight of COVID-19

Illustration by Rose Wong of people trying to hold up a giant weight
Rose Wong

When COVID-19 raged across the globe in early 2020, people were terrified of the novel pathogen. Health-care professionals were taxed to their limits as hospitals filled with patients struggling to breathe. Virologists and epidemiologists worked frantically to understand the virus, while national governments disagreed over policies to contain and control it. Meanwhile, Columbia’s psychologists and psychiatrists began to prepare for a second pandemic: one of widespread mental-health challenges.

“There’s a link between events where people have traumatic experiences and then some sort of psychological sequelae,” explains Jeffrey Lieberman, chair of the Department of Psychiatry at the Vagelos College of Physicians and Surgeons. But predicting the exact psychological sequelae, or mental-health effects, of the COVID-19 pandemic presented a challenge.

Researchers look to historical precedent to deduce what will happen in response to a traumatic event. Data suggests that natural disasters like hurricanes and tornadoes and geopolitical tragedies like terrorist attacks and war can all take a tremendous toll on the psyche. But, as Lieberman explains, nothing as pervasive and prolonged as the COVID-19 pandemic has happened in the US in recent history. The Spanish flu, the Great Depression, and World War II occurred before disaster psychiatry and disaster epidemiology were fully developed. Data from more recent, more limited, or more local disasters suggests that the demand for psychological support, whose use soared during the worst of the pandemic, will continue for months, if not years. After Hurricane Katrina, rates of posttraumatic stress disorder in people whose homes were destroyed or damaged remained high even five years later. And after the Chernobyl nuclear disaster, first responders still had elevated rates of depression and PTSD two decades after the explosion.

“What the data shows very consistently is that the psychological footprint tends to exceed the medical footprint in size and duration,” explains Lou Baptista ’14PH, associate professor of psychiatry at Columbia University Irving Medical Center and vice chair for clinical services in the Department of Psychiatry. “Some people can become depressed or develop panic attacks or have exacerbations of substance abuse during the acute phase of a disaster. Some people can start experiencing psychological challenges in the immediate aftermath, when things start to normalize. Some people might feel the effects even later.”

One of the most widespread mental-health challenges will be coping with the anguish of loss. “There will continue to be delayed traumatic responses, in health-care workers and in people who haven’t had the opportunity to deal with grief,” says Kathleen Sikkema, chair of the Department of Sociomedical Sciences at the Mailman School of Public Health. “Grief was so disjointed. People who lost loved ones were not able to participate in routine but important bereavement rituals.” And there were other losses. Sikkema says people will need to grieve for job losses and failed businesses, loss of financial security and restricted freedom of travel, loss of a social life and postponed weddings and graduations.

While all of us have been affected by COVID-19, some are more vulnerable to long-term mental-health effects. “For some individuals who have a predisposition or constitutional susceptibility to a particular disorder, the pandemic will be the precipitant that causes them to manifest symptoms of that disorder,” says Lieberman. So while the pandemic won’t affect the number of people suffering from neurological or mental-health disorders like autism, schizophrenia, or Alzheimer’s disease, it will increase the number suffering from depression, anxiety, obsessive-compulsive disorder, PTSD, and phobic disorders. These conditions could persist for quite a while. “During a crisis, people tend to rise to the occasion and meet the challenge. Adrenaline is flowing,” says Lieberman. “But the aftermath is when these conditions will occur and will continue to occur, over a period of several years.” The pandemic may also exacerbate complications of these conditions, “including self-medicating with alcohol or recreational intoxicants, substance abuse, suicide, and violent behavior. We’ve seen some degree of that already,” he says. In July the US government reported that overdose deaths rose 29 percent in 2020, to a total of 93,000 lives lost. This disturbing uptick is expected to continue. “We’ll see more over time,” says Lieberman.

As many physicians across the US turn their attention to understanding the prolonged physical effects of viral infection (so-called long COVID), mental-health professionals at Columbia and other leading medical centers are gearing up to provide care and resources for those who are experiencing lingering psychological challenges.

“We have to try to look ahead and anticipate the infrastructure and the capacity needed to support our community,” says Baptista. “Yes, recovery is still the norm, but we do expect an increase in mental-health needs in the months and years to come.”

One way to think of the pandemic, says Sikkema, is as a year and a half of collective trauma. “When you have these kinds of traumatic experiences, regardless of how severe, they don’t just disappear. Our lives were disrupted for a year and a half in ways that no one could imagine. Some people will be resilient and go back to the way they had been before. But most people will be changed in some way.”


Bringing mental-health resources to communities that need them most

At the beginning of the pandemic, the message was one of unity: we’re all in this together. But it didn’t take long for the flaws in that rallying cry to become evident. People of color and the socioeconomically disadvantaged were disproportionately affected by the coronavirus and therefore most in need of mental-health resources. These overlapping demographics have traditionally been underserved.

“We talk about ‘food deserts’ — areas that don’t have access to healthy food and fresh produce. Well, those same areas can be mental-health deserts,” says Sikkema.

Mental health is influenced by food security, access to education, and other social, political, and economic factors that often weigh heavily on people of color. The racial unrest mobilized by the murder of George Floyd in the midst of the pandemic added to an already high level of stress. “Rates of anxiety and depression spiked in the Black community after George Floyd’s murder,” says Sikkema. “So much of our mental-health treatment is not as culturally tailored as it should be.”

“Clinicians can be racist and can be perceived as racist by patients,” says Sidney H. Hankerson, assistant professor of clinical psychiatry at Columbia. “It’s important to acknowledge that.”

Hankerson adds that structural racism also inevitably affects patients’ lives. “For example,” he says, “Black adults with depression have more severe symptoms and a longer course of illness compared to white adults, yet Black adults have lower treatment rates.”

One important step in reducing disparities across communities is encouraging more underrepresented minorities to enter mental-health professions. “We need to find more funding to get more people into the field so we have a more diverse mental-health workforce,” says Sikkema.

Illustration by Rose Wong of a woman looking at flowers on top of a large hill
Rose Wong

While academic centers are actively working on achieving that longer-term goal, the University is helping to deliver mental-health information and treatment to vulnerable members of its surrounding communities. “Programs to identify mental-health-care needs in the community and facilitate access to treatment existed pre-pandemic, but now there’s a push to expand them,” says Jean-Marie E. Alves-Bradford, director of Columbia Psychiatry’s Office of Equity, Diversity, and Inclusion.

One effective way to reach people in underserved areas is by providing community-based support and training religious leaders, teachers, and even hairdressers and barbers to recognize signs of mental distress. “We’re getting people trained and getting mental health integrated into places where there is key trust in others,” says Sikkema.

Hankerson is involved in a project that trains church members in Harlem to screen people for depression and provide counseling. The project aims to overcome the cultural mistrust and stigma that can prevent some in the African-American community from seeking mental-health services. Recently Hankerson and his colleague Milton Wainberg, a professor of clinical psychiatry, received a $750,000 federal grant that will help them expand their work to Washington Heights and the West Bronx. Eventually they hope to expand the project to other parts of the state and even beyond.

Another innovative new outreach initiative is the psychiatry department’s Post-COVID Community Mental Health Project, funded by the Leon Levy Foundation. Working with the National Black Leadership Commission on Health and the New York Public Library, the project sets out to increase public access to mental-health information. “We want to engage communities in a dialogue about their needs, and we’ve already completed community roundtables with residents in northern Manhattan and the Bronx,” explains Linda Rosenberg, executive director of external relations for the psychiatry department. Ten mental-health topics — targeted to the general population, seniors, young adults, and teens — have been chosen based on these roundtables, and Columbia Psychiatry will produce a series of educational videos on these topics. Local libraries will purchase books, distribute and promote materials, and host a series of virtual community-education forums.

“The pandemic has exacerbated longstanding disparities in mental-health treatment,” says Lieberman. “But this can be a time of opportunity. Our goal is to deliver accessible and accurate information that reduces distress and trauma, builds resilience, and, when needed, helps people find treatment.”


Supporting kids and teens

Parents were relieved to find out that the novel coronavirus appears to have less dire physical effects on young children and adolescents, at least on average. But kids and teens are certainly vulnerable to the psychological toll of the pandemic. Visits to pediatric emergency rooms for mental-health symptoms are up across the country, and there’s a severe shortage of child psychiatrists and residential facilities for treatment. The need existed before COVID-19, but it has been sharply accentuated by the pandemic.

“The million-dollar question is whether the mental-health issues created or exacerbated by the pandemic will be short-term or longer-lasting in children and teenagers,” says Anne Marie Albano, a clinical psychologist in the Department of Psychiatry and the founder of the Columbia University Clinic for Anxiety and Related Disorders.

“For the majority of kids — kids who had solid connections with their family and friends, were developing in the typical way, and were doing OK in school — the pandemic will eventually be an experience that’s in the rearview mirror,” says Albano, who specializes in treating children, adolescents, and young adults. “These kids may have experienced anxiety adjusting to teleschooling and other disruptions, but they’ll be OK.” However, she adds, kids who had preexisting anxiety or depression, kids with adaptive or maturity issues, LGBTQ kids, and kids from communities lacking resources to provide extra help may be at greater risk.

As children across the country are returning to full-time, in-person classroom education, mental-health professionals suggest that parents be patient and not expect an instant return to normalcy. Different kids, even within the same family, will have different reactions to the change in routine. “Some kids will be fine on day one. But there will always be kids who struggle more,” says Baptista. “Imagine socially anxious kids who have been home for all this time and now they have to go back. Some of these kids will take weeks or perhaps months to adjust to a new routine. For a lot of kids, this reintroduction is going to be very difficult and very triggering.”

Illustration by Rose Wong of a mother and child in an upside down bedroom
Rose Wong

Schools with sufficient resources may be able to provide access to counselors and tutors to help struggling students get up to speed. But parents can do a lot to mitigate their children’s stress. Baptista recommends that caregivers moderate their own apprehension and anxiety, especially around younger children. “If caregivers and parents are showing a lot of anxiety, the kids will pick up on that, and it will affect their own level of confidence and anxiety,” he says.

“Reassurance is also a significant tool that parents have,” Baptista says. “Reassure constantly and proactively. And listen to your kids. Often we assume that our concerns are the same as theirs. Take the time to ask questions. Your kids might be worrying about something that you didn’t even think about, and you can engage them in finding a solution.”

Albano urges parents of kids struggling with transitions to boost their children’s self-confidence by giving them age-appropriate opportunities for more independence at home and by encouraging them to deal with everyday disappointments. “Help your kids set reasonable small goals that give them a sense of ownership over the things they do,” she says. And, she adds, considering how insular many lives have been over the past year and a half, “some of these goals should be altruistic. You want to encourage your children to become young adults who will participate in the broader world.”

For children, especially young children, Baptista says the pandemic can be thought of as “a forced regression. Kids will be a year older chronologically but not necessarily socially or emotionally more mature. It was a developmental arrest in a way.” Fortunately, the majority of kids will make up for lost time quickly. “We have to be optimistic and understand kids are resilient. Most kids will catch up.”


The importance of self-care

As experts have noted, the demand for mental-health services rose during the pandemic and is expected not only to continue but to increase even as cases of COVID-19 decline. But while some people require professional counseling for pandemic-sparked psychological challenges, others can manage their own health and well-being through self-care.

And yet self-care became notably more difficult during the COVID crisis, because people could not rely on many of the strategies they had previously employed to handle stress and bring joy, says Baptista. Get-togethers with friends and family, meals out, travel, gym workouts, salon haircuts, spa manicures, movies, concerts, and museum visits were all off-limits.

As the world opens up, most of these activities are becoming available again, but professionals suggest that we could all benefit from learning additional self-care strategies to bolster our emotional well-being. Claude Ann Mellins, a professor of medical psychology in psychiatry and sociomedical sciences and the codirector of the office of clinical psychology, encourages people to practice mindfulness as a general coping strategy. “We know that trauma keeps your brain in the past, reliving things, or in the future, worrying they’ll happen again. It’s hard to feel settled. Taking just a few minutes to ground yourself in the present is a healthy way of reducing anxiety and stress.”

Illustration by Rose Wong of people on a bridge
Rose Wong

Cultivating a sense of gratitude is another important coping skill, she says, adding that it can be helpful for people to keep a journal by their bed and make a note of something they’re grateful for at the end of each day. “There’s some interesting research that shows that when people are given the opportunity to express gratitude, there’s actually a psychological and physiological improvement.”

The coping mechanisms and self-care strategies people develop now will certainly be beneficial for getting through life challenges in the future. “There’s a concept called traumatic growth: we go through periods of adversity or significant stress and we learn something from that experience that we carry with us,” says Baptista. “Maybe we don’t need to go back to the way things were exactly. Many of us have become more aware of our emotional reactions and how we react to chronic, prolonged stress both physically and mentally. So many more people now see the value of being kind and supportive to each other. We’ve discovered that building community is a form of self-care. That’s a great gain that should not go away.”


An opportunity to shift attitudes and move forward

While the pandemic has caused so much suffering, psychologists and psychiatrists see a silver lining in the new public attention focused on mental-health needs and the increased willingness of an empathetic public to make care more available. “There’s been so much discussion about well-being and resilience and the need to pay attention to our mental health,” says Elizabeth Fitelson ’03VPS, director of the Women’s Program in the Department of Psychiatry. “My hope is that as more people experience symptoms and recognize their vulnerabilities, mental health will be discussed more publicly and there will be opportunity for a shift in attitude and hopefully more resources.”

The fact that the pandemic was a global phenomenon means that anxiety and other psychological symptoms were experienced — to a greater or lesser degree — by almost everyone. That shared experience has decreased the stigma around asking for professional help. “Normalizing what people are experiencing redefines asking for help as a sign of strength,” says Mellins. Mellins lauds public figures like gymnast Simone Biles and Prince Harry who have come forward to talk about their own mental-health struggles. “People don’t know how to label what they’re experiencing; they feel so much better when it’s validated as a normal response,” she says.

Another major form of progress was the rapid rise of telemedicine. It showed that mental-health services can be delivered to people regardless of where they live or work. The challenge for the profession will be training enough providers to meet the increased demand. “Every mental-health provider I know has a waiting list now,” says Mellins. “People who were in treatment are not leaving. People who weren’t in treatment now want to be in treatment. People are asking for therapists for children, for young adults, for themselves. Across the country I think everyone is grappling with this demand and trying to create programs.”

Illustration by Rose Wong of a person overwhelmed by negative thoughts
Rose Wong

Many experts hope that this demand will drive countries to prioritize mental-health care and deliver it to all who need it. “The usual way psychological disorders are treated in America, which is not the preferred way, is that people develop symptoms, and if they’re bad enough they’ll seek treatment,” explains Lieberman. “But a better way would be to be more proactive and to have already initiated a public mental-health plan to deal with the aftereffects of the pandemic.”

Lieberman says that a false distinction between physical and mental health still stands in the way of providing quality care for all. “If there were a national health threat like salmonella in produce or contamination of the atmosphere by a volcano, the CDC and other government health officials would do something about it,” says Lieberman. “What we’re facing here is a national threat to the psyche of the population. It’s a legitimate public-health threat, and certain people are going to be much more vulnerable.”

Baptista, too, hopes that the pandemic will turn out to be an impetus for change. “Even before the pandemic, there were significant limitations on accessing mental-health care,” he says. “But so many more people have required some additional support that asking for help has become more normalized. We have to keep the momentum going, because the need is going to be great for years to come.”