Sounding the mental health alarm

For many Americans, aspects of ordinary life — working in an office, going to school, eating inside a restaurant, hugging a friend — still feel impossibly unsafe.

Amid continued uncertainty about when the COVID-19 pandemic will be brought under control, Stanford mental health experts are planning for the psychological fallout of having an entire population under prolonged stress.

“We’ve all been talking about virus surges. What we’ve been preparing for in psychiatry is a surge in mental health problems,” said child and adolescent psychiatrist Victor Carrion, MD, director of Stanford Early Life Stress and Resilience Program.

Such a surge was well underway as early as March and continues today. In late March, the Kaiser Family Foundation conducted a poll asking American adults whether pandemic-related worries were harming their mental health; 45% said they were. By the end of July, that figure had risen to 53%.

Other indicators, such as more phone calls to hotlines designed for reporting child and domestic abuse, worry experts, too.

The emotional consequences of the pandemic will vary, said Carrion, the John A. Turner, MD, Endowed Professor for Child and Adolescent Psychiatry. Some people are discovering strengths, including the capacity to adapt to the strange circumstances and support their loved ones.

But others are finding their coping skills overwhelmed. This group could experience increases in post-traumatic stress disorder, anxiety and depression, as well as greater rates of substance abuse and domestic violence.

Although the pandemic affects everyone, certain groups are more vulnerable, including the young, older adults, people with pre-existing mental health conditions, individuals adversely affected by racism or gender discrimination, frontline health care workers, and people experiencing economic losses. Stanford psychologists and psychiatrists are using a variety of tactics to help.

How do disasters affect us?

Previous research on the mental health status of those who survive wars, natural disasters and other catastrophes shows that, although they might feel distressed, the majority of people recover without long-term psychological problems. The Stanford experts are seeing this in their day-to-day interactions during the pandemic.

“I’ve been pleasantly surprised by how resourceful people have been,” said Shaili Jain, MD, clinical associate professor of psychiatry and behavioral sciences. “I’ve had conversations with people who I was concerned about, but they are doing well.”

Still, she knows that losses during the pandemic will tip some people from successfully coping into being unable to adapt, with mental health consequences that include PTSD, which is characterized by flashbacks, avoidance of circumstances that resemble the original trauma and emotional numbing.

“I think people have experienced micro-traumas: loss of a way of life, perhaps a job, maybe their perception of how safe and predictable the world is,” she said. “And it happened suddenly. The sudden bit is what I, as a PTSD specialist, associate with a traumatic response.”

Depending on their proximity to a disaster — whether they’re a victim, rescue worker or member of the general population — 5% to 40% of people will experience PTSD. The number rises to nearly 100% in certain situations, such as among children who witness random acts of extreme violence. Incidences of major depression and substance abuse also increase after a disaster, especially in people who have a history of these conditions.

“PTSD correlates closely with economic adversity and unemployment,” Jain said. “We know trauma trickles down in financial hardship. Intimate partner violence and family violence go up. We’ll see the downstream consequences in the weeks, months and years ahead.”

Historically, for every 1% increase in unemployment among adults, there is a 25% increase in child neglect and a 12% increase in physical abuse of children, Carrion said. Unemployment reached its highest level since the Great Depression, jumping from 3.5% in February to 14.7% in April before declining to 8.4% in September.

After an initial decline in calls to trauma hotlines during the earliest days of shelter-in-place orders, child abuse reports rose 22% by the end of March with 70% of reporters identifying abuse perpetrators as family members. Reports of child-abuse injuries in emergency departments also rose.

For people in more stable and safe situations, pandemic-related isolation is still likely to tax their emotional health.

This is especially true for people at vulnerable life stages, such as young children, who need interaction to build social skills; teens, who thrive on feeling valued by their peers; new parents, who need in-person help from friends and family during the exhausting newborn days; family members caring for vulnerable adults; and older adults, who are more likely than other age groups to live alone and are more medically susceptible to the novel coronavirus.

“Isolation is very much related to depression, which has significant impacts on health and can lead to suicide,” Carrion said.

With kids, he added, stress doesn’t need to rise to the level of trauma to harm well-being. “We worry about developmental milestones that may be delayed because play and other social interactions are limited.”

Even people with social phobias, who might initially have felt relieved to stay home, can be hurt by isolation, Carrion added: “If people have intense, persistent fear of being embarrassed by others, isolation maintains that anxiety and strengthens the association between anxiety and socializing.”

How to get through

With a resolution to the COVID-19 pandemic still distant, Carrion, Jain and their colleagues are helping others cope.

“Humans can cope with incredibly stressful situations when they feel they’re empowered to deal with it,” Jain said, noting that good social support is a key protective factor during and in the aftermath of stressful events.

Jain worries about frontline health workers because they’re especially likely to show delayed psychological responses; there have even been high-profile instances of health care workers dying by suicide during the pandemic.

Not only are they under extraordinary strain from the uncertainties of treating an infectious disease but health care professionals are also accustomed to temporarily sidelining their emotions to focus on patients’ distress, she said.

“It’s normal, in the moment, to leave the processing to later, but I think the processing has to happen,” Jain said. “When they’re ready to do it, it’s really good if people are met with a spirit of openness and compassion from whomever they want to share with.”

One early effort to provide such support was led by Debra Kaysen, PhD, professor of psychiatry and behavioral sciences, and Ryan Matlow, PhD, clinical assistant professor of psychiatry and behavioral sciences.

Using principles of psychological first aid, a concept developed by the National Child Traumatic Stress Network in response to disasters, Kaysen and Matlow trained a few dozen colleagues to lead one-hour “connect and recharge” groups online. The groups were offered from March to June for all staff at Stanford Healthcare and Stanford Children’s Health.

“We started each session by offering some psychoeducation — ‘Here are the expected responses to a global crisis’ — to normalize what was happening, and really just give people a space to talk about what was going on,” Matlow said. Participants then discussed their specific concerns and planned strategies they could use to manage stress and meet their own emotional needs.

“Children are not resilient just by nature of being children.” 

Session facilitators encouraged them to find time for their favorite healthy modes of coping, such as exercise, meditating, improving sleep or making time for a phone call with a supportive friend.

The sessions also included opportunities to problem-solve about common challenges, such as how to manage conflict at work or at home when everyone around you is stressed out. Session leaders connected participants to other mental health services if necessary.

Evidence suggests that we can all benefit from emotional support, and that we should keep up with phone calls, video chats and other connections to the people we care about. There may even be hidden social benefits to the pandemic because, unlike previous disasters, it affects everyone. Jain hopes that the shared experience will boost empathy for people in difficult circumstances.

Social support is especially important for kids and teens, Carrion said. “Children are not resilient just by nature of being children,” he said, noting the common misconception that children automatically bounce back from bad experiences.

Although a consistent predictor of children’s resilience is having at least one adult in their lives whom they can count on, other factors also foster resilience, such as perseverance, the ability to think about multiple things at once and consciously regulating emotional responses. Adults can encourage and facilitate these skills by modeling them and by engaging with the children in their lives.

Right now, parents can set their children up for a healthy reaction to the pandemic by giving age-appropriate answers to their questions about the COVID-19 crisis, listening to and helping assuage their fears, helping them maintain virtual connections to friends, and giving them a sense of agency — even if it’s simply letting them pick a new ice cream flavor for dessert.

“I have been surprised to see how well many children coped with the early phase,” Carrion said. “During the first phase of our shelter in place, they may have enjoyed being home and having their parents around a bit more. But as our crisis continues and this is now becoming a chronic stressor, we need to be vigilant of children’s reactions.”

For teens, maintaining some normal social markers of healthy adolescent development is important, too. Carrion recommends giving them space to interact with their peers without parents around, such as leaving them alone to video chat with friends.

It is also important to recognize their opinions and thoughts about current events by including them in conversation and encouraging them to record or write about their experience.

“Many healthy ways of coping have been taken away. Things like support groups, Alcoholics Anonymous meetings, going to the gym for a workout: People really rely on those.”

To help support people across California, Carrion is rolling out a statewide program to teach psychological first aid and skills for psychological recovery to counties’ mental health staffers.

Tailored to address pandemic-related stressors, this psychological training is intended for psychologists, psychiatrists, social workers, people who answer calls to crisis hotlines and anyone interacting with clients, including receptionists and clinic managers at county behavioral health clinics. The sessions began in September.

“The staff are being equipped to do a basic stress and resilience intervention so they can treat their clients and communities,” Carrion said.

Carrion also helps disseminate information for parents about how to look after themselves and their kids, and how to communicate with children on challenging subjects, such as the pandemic and racial injustice.

He’s been a key source for local and national media stories on the topic, and is conducting online seminars for a variety of audiences.

It’s also important that people who already have mental health diagnoses continue receiving treatment during the pandemic, he said.

Many mental health providers have been able to transition to phone or videoconference appointments, though Carrion noted that barriers to treatment accessibility are far from over. (Pre-pandemic, two-thirds of the children in America who needed mental health services did not get them.)

And self-care is more important than ever, experts say, including getting enough sleep and exercise and eating well; moderating screen time; and engaging in restorative experiences such as meditating, praying or spending quiet time in nature.

“Many healthy ways of coping have been taken away,” Jain said. “Things like support groups, Alcoholics Anonymous meetings, going to the gym for a workout: People really rely on those. And little organic opportunities for social interaction that lift up your day are no longer there.”

In light of all this, Jain stressed the importance of being kind to yourself. In a phone call this spring, Jain’s elderly mother was lamenting the cancellation of their family’s summer plans and Jain gently reminded her to acknowledge what she had achieved: “I said, ‘Mom, you’ve kept yourself alive, kept Dad alive, and neither of you has gotten sick. That’s a huge accomplishment.’”

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