For nearly 15 months, the Covid-19 pandemic has halted everyday life in the United States and much of the world. As in-person interactions shifted to screens, tens of millions of people were forced to adapt to life under the persistent threat of a lethal virus. Although vaccines have tempered cases, Americans have been subjected to a year of isolation and uncertainty, taking a significant toll on their mental health.
Researchers, clinical psychologists, and practicing psychiatrists at Harvard-affiliated hospitals have attempted to quantify and respond to the unprecedented national anguish while addressing persistent inequities in access to mental health resources and care.
More than 41 percent of Americans over the age of 18 reported symptoms of anxiety or depression during the pandemic, compared to 10.8 percent of adults in 2019, according to the Centers for Disease Control and Prevention.
“Those levels are kind of unprecedented in modern times,” said Christopher M. Palmer, a professor of psychiatry at Harvard Medical School.
Rates of post-traumatic stress disorder and substance abuse have also skyrocketed, in addition to major risk factors of mental illness such as intimate partner violence and child abuse, according to Jordan W. Smoller ’83, a professor of psychiatry at Harvard Medical School and a professor of epidemiology at the Harvard School of Public Health.
Many whose symptoms go undiagnosed do not recognize that they have a mental health problem, according to Palmer. Instead, they see their mental distress as a temporary result of the pandemic and the stringent measures that come with it — like lockdown, quarantine, and masks.
Regardless, the mental health symptoms accrued over the past year are set to pose a significant public health challenge in the years to come.
Umadevi Naidoo, the director of Nutritional and Lifestyle Psychiatry at Massachusetts General Hospital, dubbed mental health issues the “silent pandemic”: out of the daily headlines but a serious threat to the public.
Psychiatrists and clinical psychologists at Harvard hospitals have observed these national trends in their own patients, according to Gregory L. Fricchione, the associate chief of psychiatry at MGH.
Palmer agreed, noting many of his own patients reported increased symptoms throughout the pandemic, including feeling more isolated, frustrated, depressed, despondent, and hopeless.
These symptoms have crossed generational lines, but have been particularly pronounced among young people, who have sacrificed significant milestones in their lives to combat a virus that poses less of a physical threat to their demographic.
In a survey, Cindy H. Liu, an assistant professor of pediatrics at the Medical School, found that 40 to 45 percent of surveyed young adults across the country reported experiencing mental distress.
Liu said the anxieties and disruptions caused by the Covid-19 era — from the fear of transmitting the virus to loved ones to the loss of in-person graduations — took a toll on young people's well-being.
“There’s an entire generation that missed all of those fun things that the rest of us have had,” Naidoo said. “None of it happened, and it’s like taking a piece of someone’s history out.”
Young people were also unsettled by the social and political unrest that rippled across the nation over the past year, according to Liu.
Older people also experienced psychological repercussions of a remote year. Many feared their increased vulnerability to the virus and struggled to use technology to engage with loved ones, according to Daiane B. Machado, a research fellow in Global Health and Social Medicine at the Medical School.
“Many older people had to stay locked at home, and many of them don’t have access to technology, or if they do, they find it much more difficult to use,” Machado said.
“They were not seeing their family, they were not having the support they needed. They got very anxious, many had very poor quality sleep, and some got depressed especially as the pandemic continued,” added Zeina N. Chemali, a professor of psychiatry and neurology at the Medical School.
Americans seeking care during the current crisis have encountered long-standing racial, economic, and geographic inequities that plague the country’s mental health care system, which has struggled to respond to the unprecedented national distress.
“Even before the pandemic, the mental health care system in the U.S. and indeed around the world was failing to meet the needs of the majority of people who are affected by mental health problems,” said Vikram H. Patel, a global health professor at the Medical School. “The need has now absolutely boomed because of the pandemic, and the system as it is is completely incapable of addressing this need.”
In the U.S., people of color, low-income populations, and those with pre-existing mental health conditions are disproportionately experiencing the psychological fallout of the pandemic, according to Smoller.
Some clinicians have sought to directly reach out to vulnerable groups. A program at Massachusetts General Hospital called Community Psychiatry PRIDE, directed by clinical psychologist Luana Marques, aims to implement evidence-based treatments to increase quality mental health care access in underserved populations.
Before the pandemic began, Marques and her team trained non-licensed professionals to deliver cognitive behavioral therapy, a form of treatment that involves changing destructive thinking patterns. As the pandemic raged in lower-income communities, these newly-trained mental health professionals were deployed to help struggling young people build emotional recognition and resilience skills.
The shift to telemedicine has also helped clinicians expand the reach of mental health services. The ability to provide care virtually has been a “godsend,” according to John B. Herman, the associate chief of psychiatry at MGH.
Prior to the pandemic, only around 5 percent of all patient visits at MGH were virtual. Within the first month of the pandemic, nearly 95 percent of visits were virtual, Smoller said.
“For a lot of people who are practitioners and patients, it’s just a lot more convenient,” Patel said. “Rates of non-attendance have dropped, and more importantly, the cost to patients has dropped because they no longer have to take time off and travel to hospitals and then wait for a long time.”
Telemedicine in psychiatric practices, however, can have notable downsides. The effectiveness of virtual consultations is limited by the privacy and comfort levels individuals have in their own homes, according to S. Bryn Austin, a professor at HSPH.
“If someone lives in a home where there’s a lot of other people there, maybe there’s multiple families in a home, they don’t have a private space to be able to do tele-mental health care — they still don't have access,” Austin said.
“We cannot assume that telemedicine is going to be the great equalizer,” Patel added. “It could in fact be the opposite.”
When talking on screens, clinicians cannot use physical touch and gestures to connect with their patients. Chemali said that many of her elderly clients value one-on-one intimate communication, including smiling, shaking hands, and getting to know their physician.
Palmer also said he found it difficult to communicate effectively through Zoom.
“Sitting with another human being in person is a very different experience than sitting with someone on Zoom,” he said. “You don't make eye contact on Zoom. If you’re trying to make eye contact, it means that you’re looking at a camera, and you’re not looking at the person — and you miss out on all of the other nonverbal body language.”
Furthermore, telehealth can be difficult for patients in remote areas without reliable internet access, further entrenching geographic and economic disparities.
“There is still a digital divide in this country where not everybody has access to all the technology or the bandwidth — literally the bandwidth — to make use of that,” Smoller said.
Austin said these challenges illustrate the necessity of developing strategies for telehealth care.
“The job’s not done yet. We have to make sure that it’s maintained, and that we continue to solve these dilemmas around economic inequities and who has access to internet and having safe spaces to be able to have these appointments,” Austin said.
Even before Covid-19, America was embroiled in a mental health crisis. Though rates of suicide and substance abuse disorders have been skyrocketing for years, Americans still struggle to access treatment.
To respond to the current moment, psychiatrists and psychologists affiliated with Harvard said they believe the University should take a proactive role in promoting mental health and wellness.
Bizu Gelaye, an assistant professor of psychiatry at the Medical School, said he believes Harvard should remain alert for mental health symptoms among its students, faculty, and staff, and continue to provide mental health resources to the general public.
“I hope Harvard continues to provide training for their students and create safe spaces for building resilience — promoting mental health is important,” Gelaye said. “I’m encouraged by those initiatives. I hope they don’t stop because this is just the tip of the iceberg.”
Liu said psychiatry research efforts should be future-facing in order to provide effective mental health care even after the pandemic.
“We need to think five steps ahead and go, ‘What would life be like in six months to a year? And what is it that we need to collect now in order to provide an understanding for what is next and how best to serve patients, members of the communities, and students at that point?’” Liu said.
Addressing the preexisting stigma around mental health is another crucial step in responding to the crisis, according to Naidoo.
“There's a lot of shame associated with not feeling good emotionally, and what happened with the pandemic is that there were certain points that showed us that individuals are struggling,” Naidoo said.
According to Karestan C. Koenen, a professor of psychiatric epidemiology at the School of Public Health, the pandemic has illustrated the importance of mental health for overall well-being.
“I think this has made it more evident, again, how important our mental health is — it’s usually as a side note, you don’t think about it until you have a problem with it,” Koenen said. “Mental health is the foundation of all health.”
—Staff writer Ariel H. Kim can be reached at firstname.lastname@example.org.
—Staff writer Anjeli R. Macaranas can be reached at email@example.com.