The science is screaming: Americans are in turmoil.
More than 80% of U.S. adults report the nation's future is a significant source of stress, according to a report Thursday from the American Psychological Association. Americans are the unhappiest they’ve been in 50 years, according to a COVID Response Tracking Study released Monday. And a survey published this month in the medical journal JAMA found three times as many U.S. adults reporting symptoms of serious psychological distress in April as they did two years earlier.
The studies were conducted to better understand how Americans are coping during this unprecedented period, with millions sickened and more than 100,000 dead in a global pandemic, anti-racism protests gripping the country and an economy in tatters after its longest expansion in history.
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America is a nation unmoored, and experts say for many people the negative mental health impacts will outlast the current crises. Research suggests the extreme stress triggered by these events may even lead to longer-term psychiatric disorders.
The nation must prepare, experts say, for the mental health crisis that looms next.
"We are facing a culmination of crises unlike anything we have seen in our lifetimes – in coronavirus, economic turmoil and racism," said Jaime Diaz-Granados, deputy chief executive officer and acting chief scientific officer at the American Psychological Association (APA).
"Each of these crises are taking a heavy psychological toll on Americans and particularly our African American citizens and other people of color. The health consequences could be dire. As we look toward the future, we need to consider the long-term implications of the collective trauma."
More than 70% of Americans in the APA report said this is the lowest point in the nation’s history they can remember. Experts say social isolation, grief, fear and uncertainty are already pervasive, and those feelings will not automatically abate when physical distancing ceases or because a handful of police officers are arrested after centuries of racial violence.
"These events absolutely will, for a large segment of our population, have long-term mental health consequences, including leading to diagnosable conditions," said Vaile Wright, senior director of health care innovation at the APA.
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Psychological distress could lead to psychiatric disorders
Beth McGinty, lead author of the JAMA study and an associate professor at Johns Hopkins Bloomberg School of Public Health, said in April 2018, about 4% of American adults reported serious psychological distress, which has been typical for the past decade. When she conducted her survey in April, that number had more than tripled.
"It's huge," McGinty said. "I expected to see an increase in distress here, but to see such a major increase in this measure of serious distress, as opposed to some more mild or moderate anxiety about the situation – I was surprised by the magnitude of increase."
To measure psychological distress, researchers used The Kessler Screening Scale for Psychological Distress, which asks questions about symptoms of depression and anxiety that occurred in the past 30 days, including, "How often did you feel hopeless?" and "How often did you feel worthless?"
In the study, the authors note "acute distress during COVID-19 may transfer to longer-term psychiatric disorders" because serious psychological distress as measured by the Kessler scale has been shown to predict clinical mental illness.
"It's not a perfect prediction," McGinty said. "It is not a diagnostic tool. It doesn't mean that every single person who had serious psychological distress in April is going to go on to develop a clinical diagnosis of depression or anxiety, for example. But it means that they are very much at risk of going on to develop that clinical diagnosis."
Front line workers, people of color, those in COVID-19 hotspots at high risk
Certain populations are at higher risk of developing serious mental health conditions, experts say.
Those who live in geographic areas severely impacted by COVID-19 are more vulnerable, as are those who may have lost a loved one to the virus.
People previously diagnosed with a mental health condition are more likely to feel psychological distress. Experts say those with preexisting depression, anxiety, substance use, or eating disorders are likely heavily triggered in the current climate.
Front line workers, particularly health care workers, are at risk for developing a series of lingering effects, including post-traumatic stress disorder, Wright said. Many are exhausted and struggling with the deaths of patients and colleagues.
Sustained stress also is of particular concern for those suffering from systemic stressors – poverty, discrimination, lack of opportunities – as they have fewer coping resources.
Research shows Black Americans are 20% more likely to report serious psychological distress than non-Hispanic white Americans. According to the APA, the proportion of Black adults who say discrimination is a significant source of stress has increased from 42% to 55% in the past month as protests erupted across the country in response to several high-profile incidents of racial violence, including George Floyd, Ahmaud Arbery, Breonna Taylor, and Rayshard Brooks.
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Why loneliness may not be the problem
One of the study findings that surprised McGinty was that there wasn't a significant increase in people who reported feeling lonely. Loneliness increased slightly relative to pre-COVID-19 levels, but not much. This was also true in the COVID Response Tracking Study, which found loneliness had increased but was not as prevalent as researchers expected.
This suggests loneliness is not the main driver of psychological distress. People are finding ways to connect, albeit differently. Researchers say other factors, concerns about the economy, about contracting the virus, about interrupted education, are the more likely drivers.
This is important, McGinty says, because it suggests even as social distancing eases, people will continue to struggle.
"For some groups, the longer-term consequences of the pandemic, the economic consequences, or the consequences of having a loved one who is affected by COVID ... (may lead to) increases in psychological distress," even after the pandemic is over, she said.
Stigma, lack of access could further stress the system
A 2018 survey found while most American adults say having a mental health disorder is nothing to be ashamed of, a third of respondents agreed with the statement, "People with mental health disorders scare me." And nearly 40% said they would view someone differently if they knew that person had a mental health disorder. These attitudes could prevent some people from seeking treatment.
For those who know they need care, it may not always be available or sufficient.
The APA said in 2016 11.8 million American adults believed they needed mental health services but couldn't access them. Approximately 6.3 million said they received some mental health services, but needed more. Of those who reported an unmet need, 38% said it was because they couldn't afford it, 28% said they thought they could handle the problem without treatment, and 21% said they didn't know where to go for treatment.
A June survey found more than half of responding clinicians were seeing fewer patients than before the pandemic began, which some experts say could be related to loss of health insurance.
Millions of Americans have lost their jobs as the nation shut down to slow the spread of COVID-19, and for those who get health insurance from an employer, losing a job means losing health benefits, too.
More screening, more telehealth, more connection
Experts say even if someone isn't part of a vulnerable group, sustained stress is a universal risk factor.
"When people are overwhelmed, when stressors exceed your ability to handle them, it is much harder to cope and address the concerns in day to day living," Diaz-Granados said. "As this situation continues, people's capacity to deal with additional challenges is reduced."
That's why McGinty says it's crucial for health care systems to ramp up mental health screenings, including among primary care physicians, since many mental health disorders present with physical symptoms, such as headaches, muscle tension, and stomach issues. OBGYNs also should be on the lookout, since women in particular are taking on the additional burdens of unpaid care and domestic work, as well as pediatricians, since children are suffering, too.
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Diaz-Granados said because there already is a shortage of behavioral health specialists, health care systems may need to provide more group therapy or offer stepped care, before offering individual psychological services.
Experts say it's critical that telehealth remain a viable option for people who need and want to use it, even when in-person care becomes available. It will be some time before everyone is comfortable entering a clinician's office, and telehealth allows providers to reach populations they may not have connected with otherwise.
Communities have a role to play, too. Research shows communities with high levels of social cohesion fare better than socially divided ones, Diaz-Granados said. When people can agree on shared values and goals, when they are inclusive, they are healthier.
Wright says the pandemic has de-stigmatized some mental health issues. People who never struggled with anxiety or isolation pre-COVID now have greater empathy for those who did. COVID-19 and the protests also have brought necessary attention to racism's health impacts, but in her view, there isn't enough national discussion about how profound these crises will be on long-term emotional well-being.
Wright wishes there was a mental health equivalent to Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases who became America's rock during the pandemic – someone who can talk candidly and authoritatively about mental health issues.
"There's just sort of the pandemic within the pandemic now," she said. "There's stress around getting sick or your family getting sick. There's the economic piece. It's the national rhetoric around systemic racism. Stress related to leadership. It reminds us of all the things that are out of our control, so it's imperative we try to focus on the things in our control so that we can try to maintain some of our emotional health. If we don't, then individuals are absolutely at risk of a variety of different disorders."
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Alia E. Dastagir is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @alia_e