COVID-19 Mental Health Impacts Deepened By Societal Inequities
The toll of pandemics is often measured in bodies: bodies in hospital beds, bodies in morgues, bodies in unemployment lines. But so much loss and instability exact a mental price, too — a cost beyond exhaustion, depression and anxiety.
"The COVID-19 pandemic has many characteristics of trauma or traumatic stress that are toxic to mental health," said Dr. Karestan Koenen, a professor of psychiatric epidemiology at the Harvard T.H. Chan School of Public Health.
Koenen studies trauma's long-term effects on learning, memory, cognition and physical health.
"We really need to end the way we think about mental health as sort of separate from physical health — somehow our brain is separate from our body — because it really is the foundation."
Overburdened And Overwhelmed
Studies link trauma to increased risk of diabetes, cardiovascular disease and stroke. So what does that mean for racial and ethnic minorities already overburdened with those diseases, overrepresented among COVID-19 patients and overly vulnerable due to inequities in the social determinants of health?
"Just like the virus has disproportionately affected certain communities, social factors also influence who has mental health effects," said Koenen.
In her global survey of 7,500 pregnant or recently pregnant women during COVID-19, 35% reported clinical anxiety, 30% had clinical depression and more than 40% clinical PTSD — extraordinary numbers driven by mundane concerns.
"The fundamental human needs are food, clothing and shelter. And if that's disrupted, getting everyone individual therapists isn't going to solve the problem," she said.
Koenen calls for policies that get people homes, jobs, food and counseling — both to stem the current tide of suffering and to quell adverse ripple effects across generations.
Dr. Sheri Madigan, Canada Research Chair in Determinants of Child Development at the University of Calgary and the Alberta Children's Hospital Research Institute, agrees.
"This isn't just about kids. It's not about just health workers. It's not about just parents. It's general population — everyone is really struggling."
Madigan studies how early social experiences help or hinder children's mental health.
"We really need to start thinking about this fourth wave, this mental health wave that's likely to be sustained over time, and to start to put things in place," she said.
Madigan's study has followed 1,500 mothers for the past decade. She says COVID-19 whipped up a "perfect storm" of stressors in her cohort: 60% lost income, 43% struggled financially and 5% experienced food insecurity.
"You know, moms — we tend to think of them of having some super powers, and I think they do. But I think that they are overwhelmed. And they've dug really deep, but I think it's going to take a while to get out of this," said Madigan.
Research also links parental depression and anxiety to the loss of social supports, like grandparents who can babysit or take kids to school.
"They're really struggling with that juggle of homeschooling, working from home and also the domestic responsibilities," she said.
Children are struggling, too. Madigan says almost half of tweens and teens feel anxiety and depression linked to parents' mental health, disconnection from family members, increased screen time and reduced sleep.
Dr. Ruth Shim is a professor of cultural and clinical psychiatry at the University of California, Davis. She says confronting those problems starts with broadening our perspective.
"We've maybe spent a little bit too much time in the last 40 or 50 years focusing on the biological — maybe to the extent of leaving out some of our focus on the social."
Stemming The Syndemic
Shim says we need to see COVID-19 as more than the sum of its parts — a synergistic pandemic, or "syndemic," fueled in part by mental health disparities and inequities.
"The rise in depression rates in the COVID pandemic are attributable to multiple social determinants of mental health, including unemployment, food insecurity, poverty, discrimination, adverse life experiences and poor access to healthcare," she said.
The sea change required to address such issues won't happen overnight, so what can families do to stay afloat in the meantime? Therapy, now more widely accessible online, can help. But so too can keeping to routines, says Madigan.
"When sleep routines, screen routines and school routines are consistent, kids are doing better during COVID."
Physicians and community members can help by inquiring about mental wellbeing and by sharing that it's normal to feel overwhelmed.
"By saying, 'A lot of families are really struggling. How are you doing?' So people can actually know that they're not alone," said Madigan.
Looking beyond social triage, though, experts agree: Structural weaknesses undermining mental health require structural reforms.
But really addressing the problem ultimately means addressing the underlying social determinants. That's a daunting prospect, but Shim says it's also a hopeful one, because social factors are the ones we can change.
"You know, for each one of the social determinants, individuals in their communities have come up with solutions to these problems, but it's really a matter of bringing those solutions to scale."
As an example, Shim cites purpose-built communities, which involve community members in the policy-making process.
"The outcomes are incredible in terms of overall lower rates of mental health problems and physical health problems and in general positive outcomes."
She says such approaches have created better educational systems and more affordable housing and food. The challenge lies in scaling them up.
Whether the attention COVID-19 has brought to determinants of mental health will lead to substantive reforms, one thing is clear: The disease exemplifies the old public health adage that all policies are health policies.
"What I'd like to see come out of the pandemic is that we make a choice as a society to support mental health from birth to death, and that would actually be transformative for health broadly," said Koenen.