Q&A: The Coronavirus Pandemic: Mental Health One Year Later

We last spoke in March 2020, when we were just beginning to learn about the pandemic and adjusting to life in quarantine. Now that we’ve been living this way for a year, have any of your concerns about mental health changed?

In March 2020, we were in the early stages of the pandemic. We clearly did not know how long the pandemic would be ongoing. Most of us did not imagine that we would still be living the restricted lives we are. When we spoke, we were in the immediate stages of grappling with acute pandemic-induced restrictions and losses, big and small, but now we have now been living under a prolonged period of stress, loss, and restrictions for a year. The viral and the economic impact of the pandemic, along with major political and social upheaval stemming from U.S. elections and systemic racial inequities, are all part of the collective experience in the past year.

Although data on children and families continues to be limited relative to data on adults, we now have more data about the emerging mental health impact on parents and children. Overall, the pandemic and the associated public health measures (distancing and isolating) are taking a toll on the mental health of children and adolescents across a range of metrics, including concerns related to depression, self-harm, etc. Other data on children and teens from the CDC show that the proportion of children’s mental health-related emergency department visits has increased since April 2020. In terms of the impact on parents, a recent survey by the American Psychological Association found that parents with children under age 18 were more than twice as likely as non-parent adults to have worked with a mental health professional and to have been diagnosed with a mental health disorder since the pandemic started. Also, 75% of parents reported that they could have used more emotional support than they received during the pandemic.

Of note, systematic data from the pregnancy and postpartum periods and data on young children under the age of 6 remain sparse. However, available data suggest similar patterns of growing mental health needs. For instance, our own research (paper under review) indicates high levels of anxiety/depression, post-traumatic stress symptoms, and increased loneliness among pregnant and postpartum women.¹ Whether and how this affects their infants’ development remains to be examined, but based on prior research we know that experiencing stress during sensitive periods of development (pregnancy – age 3) has important implications for parent-infant bonding and infant development, so we really need to continue to learn and intervene more.

Importantly, we need to keep in mind that the pandemic impact is not uniform across society. Due to the systemic inequities in the U.S., Black, indigenous, and people of color (BIPOC) communities have borne the brunt of the pandemic^2,3, which may have specific mental health implications for BIPOC individuals in multiple ways⁴ and need to be understood to inform intervention efforts. Relatedly, as we noted the impact of other events during the pandemic, such as the killing of Mr. George Floyd, and the subsequent racial justice protests may also impact BIPOC individuals and communities differently. For instance, in prior research, police killings of unarmed Black Americans have been associated with poor mental health of Black Americans but not White Americans⁵  and detrimentally affect achievement of BIPOC youth.

The availability of multiple efficacious vaccines, and improving access to vaccines and testing, give us hope of a closer semblance of normalization and typical life. With improvements in the pandemic public health response, and the recent economic stimulus, we would expect some relief for parents and families, particularly for those who have been financially affected, and improvements in mental health as well, even though we have a lot of work ahead of us in terms of building our bandwidth and developing responsive public health and health care systems.

Have the kinds of mental health supports necessary for children and families changed since the beginning of the pandemic? Are they more widely available?

The idea that mental health is central to health and well-being is a focus now more than ever before. The pandemic has made conversations about mental health more common and perhaps less stigmatized. So, the idea of mental health supports and ways to support children’s emotional health appears to be part of many more settings, or at least in more consistent and explicit ways, such as in school-based curriculums, primary care visits, and certainly conversations with parents or caregivers.

There have been important changes to health policies in Massachusetts (MA), making some types of mental health care more accessible. A major change in this regard is the recent MA legislation that mandates permanent payment parity for tele-mental health services with in-person services. This includes both phone and video sessions, and this is important because access to reliable internet is not always available to everyone due to existing digital access disparities.

Another element that is increasingly getting attention is the use of digital tools for mental health care that may be an effective adjunct to working with a mental health professional. Also, the use of multidisciplinary teams–whether it is through integrated care models such as integrating mental health specialists in primary pediatric care, or through the inclusion of resource specialists in a care team in addition to mental health or primary care health providers–are models that are increasingly gaining momentum.

In addition to change in the format of delivering mental health care including more flexible formats – both in terms of mode of delivery (telehealth, digital, or in-person) and the use of multidisciplinary teams, there are at least two other areas that will continue to gain traction. This includes cross-sector partnerships (e.g., mental health care collaborations with a range of community-based organizations such as schools or with law enforcement), and an increased focus on prevention rather than primarily ameliorative and tertiary care.

A new term–“pandemic fatigue”–has popped up recently. What advice do you have for families who have grown weary of the physical isolation and social limitations and precautions? And for those who may be struggling emotionally, mentally, and even financially?

The cumulative impact of various stressors – and there have been so many – makes this “last mile” as vaccines ramp up, harder. Fatigue and burnout are ubiquitous. We have come pretty far in this journey, and the horizon to safe in-person and more physically connected lives is visible with increasing vaccine access. We also still need to stay cautious and support each other in getting through this period. Parents and caregivers are the bedrock for their families, and anything we can do to prioritize caregivers’ needs and well-being is critical.

While there are no easy answers, it is helpful to revisit some ideas. For instance, it can be helpful to revisit familial rules and restrictions that people have been following. We know more about how the virus is spread, and what we can do to stay safe. With winter in our rear view, we have more options for safe outdoor meetings such as playdates for children and parents alike, while masking. Opportunities for self-care through intentional, behavioral methods that we can control can cultivate resilience. Finally, recognizing and giving ourselves permission that even as things may improve, we will likely still be coping with grief, sadness, exhaustion, etc., and need to allow ourselves the time and opportunity to process the impact of this communal trauma is key. Importantly, continue to reach out and connect-–to your friends, loved ones, and medical and mental health professionals-–for support.

One way to think about this is that resilience is not a trait that we develop in isolation. It is more of a process–often a messy one–that is primarily developed through experiencing responsiveness. For instance, when our children are coping with stress or feeling overwhelmed, having a reliable supportive caregiver makes that stressor tolerable, and children learn how to cope and adapt. In fact, at every stage in life, including in adulthood, having responsive support through family, friends, and community is important to our well-being. Indeed, one key lesson from the pandemic is the need for more family-friendly policies. For instance, the Rescue Act provides economic stimulus for families with children, includes an extension of Medicare for one-year postpartum for mothers, etc. Advocating for more family friendly policy beyond a one-time effort is critical and something we can all do.

Thinking about the months and years ahead, are there signs we should be on the lookout for when it comes to mental health consequences that might stem from the pandemic?

The longer-term impact will vary a lot based on each child and family’s individual experience of the pandemic. For those who suffered major losses-–such as bereavement, housing or food instability, a family member with significant COVID-related disease complications–there may be a long-term impact. This does not necessarily mean that children or adults with such experiences will have diagnosable mental health disorders. In fact, the majority of children and adults are unlikely to have long-term diagnosable mental health disorders, and the current levels of mental distress are likely to improve substantially, provided a consistent sense of stability can be established. However, even in the absence of a mental disorder or mental disorder symptoms, peoples’ fundamental assumptions about safety and predictability of the world are likely to be affected. This is how trauma affects us–and COVID-19 is a global communal trauma–it fundamentally reshapes our world views, including our sense of trust in others, in larger systems, and ourselves. It is important to note that even within this pandemic, many people have come together with extraordinary outpouring of support for each other, and one outgrowth of this experience may be that our hopes and efforts towards a more connected, compassionate, and equitable society may increase.

What can we do to support each other now and in the future? Do you have any advice or suggestions for policymakers, practitioners, or parents about resources they should know about or changes we need to work on to address the emotional fallout of the past year?

Recognizing that there is no health without mental health is central to planning for the future. We need significant investments in our mental health infrastructure and also to reconsider the ways in which current systems are structured. We highlight four points to consider that include both long-term and shorter-term ideas:

1. Flexible and integrative models of care such as telehealth, multidisciplinary teams, and cross-sector partnerships, as discussed above, are important next steps that should be implemented, evaluated, and expanded.
2. Centering health equity in all aspects of future planning and implementation is critical. The pandemic has made clear that while we are all in the same storm, we are not all in the same boat. The impact of systemic inequities in the U.S. on BIPOC communities has long since been established and reiterated and exacerbated in the pandemic.
3. Prevention is a major area for growth. Data suggest that at least half of lifetime mental disorders begin in childhood, and approximately 75% are diagnosed before age 25. This not only means that we need much more investment in childhood mental health research and health care access, but also that we need to support those who most closely care for our children and their emotional development-–parents, early childhood caregivers, and educators. Given what we know about sensitive periods of development especially in the pregnancy through age 3 period, greater investments in research and clinical care in this period are essential.
4. These points also serve to highlight that to reshape health care, we also need to consider the practical implications of training and education in mental health disciplines (e.g., psychiatry, psychology, social work) but really all medical specialties, and school-based roles. Training that builds on intergenerational, systemic, and life-course approaches in the science of early childhood development, trauma, resilience, and what they mean for specific disciplines, is key.

References

1. Basu A, Kim H, Basaldua R, et al. A cross-national study of factors associated with women’s perinatal mental health and wellbeing during the COVID-19 pandemic. under review. 2021.
2. Andrasfay T, Goldman N. Reductions in 2020 US life expectancy due to COVID-19 and the disproportionate impact on the Black and Latino populations. 2021;118(5 e2014746118).
3. Centers for Disease Control and Prevention. Health equity considerations and racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html.
4. Gur RE, White LK, Waller R, et al. The Disproportionate Burden of the COVID-19 Pandemic Among Pregnant Black Women. Psychiatry Res. 2020;293:113475.
5. Bor J, Venkataramani AS, Williams DR, Tsai AC. Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. The Lancet. 2018;392(10144):302-310.