The mental health toll of COVID-19

RICK WEISS: Thank you, Josh, and welcome, to everyone, to the SciLine media briefing. For those of you who may be first-timers, SciLine is a free, editorially independent service for reporters based at the nonprofit American Association for the Advancement of Science. We’re funded entirely by philanthropies to achieve one overarching goal, which is to help reporters like you get access to scientists and to research-backed scientific evidence to include in your stories, whether those stories are about the science itself or are just stories about what’s going on in your community and can be strengthened by including some science. Everything we do is free, and I encourage you all to go to the sciline.org website to see all the ways that we can help you.

Today’s briefing is going to give us insight into a particularly insidious aspect of the COVID pandemic, which is the slow-burning toll it’s taking on mental and emotional health. I want to take a moment here to acknowledge as a long-time health and medicine reporter myself that mental health stories are notoriously difficult to craft, I think in part because the range of mental illness is so vast, from seemingly benign bouts of anxiety to totally debilitating conditions, and in part because it’s just inherently so personal. But as we’re going to learn from our panelists today, a decline in mental well-being is one of the COVID pandemic’s most widespread affects, even as COVID-related deaths and physical illness seem to be abating in this country. This story is going on in every single community in America, so I hope you will take what you hear in this briefing today back to your communities and use it to help inform both those who are suffering and those who are in position to relieve some of that suffering through local policies and services.

OK, to get started, I’m not going to do big introductions of our speakers here. Their bios are on the sciline.org website. I’ll just tell you that we will hear first from Dr. Karestan Koenen, a professor of psychiatric epidemiology at Harvard, who will provide an overview of mental health symptoms observed in adults during the course of this first pandemic year and what the research says about how these damaging effects can be mitigated. Second, we’re going to hear from Dr. Sheri Madigan, who is an associate professor in psychology at the University of Calgary in Canada, who will speak about the impact of the pandemic on children’s and adolescents’ mental health and how stressors like the pandemic can influence children’s emotional development and what the research says about how parents can best support their – excuse me – their children in continuing to deal with the pandemic. And last, we’ll hear from Dr. Ruth Shim, an associate professor in psychiatry and behavioral sciences at the University of California at Davis, who will talk about the inequities in our society when it comes to who is bearing the biggest brunt of these mental health impacts and the role of structural racism and other societal factors in exacerbating these differences. So with that, let’s get started. Over to you, Karestan Koenen.

[0:03:10]

KARESTAN KOENEN: Thanks, Rick, and I’m really excited to be here. And I’m going to share some slides. OK, and – OK. So thank you for having me today. So I’m going to talk – as Rick said, I’m going to talk about adult mental health and COVID-19. So as I think many people know, the COVID-19 pandemic has many characteristics of trauma or traumatic stress that we – that are toxic to mental health. So when we think of trauma, one of the questions I’m always asked – is COVID-19 a traumatic stressor? We think of – the defining characteristics of trauma are usually threats, unpredictability and the lack of control of the person who has – is experiencing the trauma. And so I think that we can all agree, over the last 15 months, we’ve all experienced threat, unpredictability and lack of control. In addition, in COVID, there’s been a lot of other stressors that we know are toxic to mental health related to the efforts to stem the infection. So there’s been closings, problems with jobs and the economy shortages.

And in addition, there’s been three other things that we know are toxic to mental health. There’s been bereavement. I think it’s now 3.7 million people have died – social isolation, again, during – doing the infection control measures and stigma, whether it’s of people who are thought to be high carriers of COVID or certain population groups. And so all of this together has really created a perfect storm of conditions for short- and long-term mental health problems. So what are we actually seeing? So in one study, we did – and I’m just going to use this as an example. We did a global survey of pregnant or recently pregnant women, which this is about 7,500 women from 64 countries. And they reported on their mental health, among other things. And if you look on this slide all the way over to the right, you can see that in this sample, which was pregnant or recently pregnant women, over 35% reported clinical levels of anxiety, about 30% clinical levels of depression and over 40% clinical levels of PTSD. And these were higher – not only higher than we see in pregnant and postpartum women before COVID, but also really significantly higher than most general population studies in terms of mental health.

So we’re seeing this elevations in mental health problems, and then elevations in certain groups. In this case, it was pregnant and postpartum women. And one of the questions that come – has come up is, do we know that mental health’s gotten worse during the pandemic? I think, you know, we all anecdotally maybe talk about that, but do we really have data? And now we have a number of studies – I’m just showing one here, which looks at, for example, levels of depression in the U.S. before COVID – these are data from 2017, 2018; that’s in the blue – and clinical levels of depression during COVID, and you can – which is in the red. And you can see the shift. You can see the shift that before COVID, over 75% of the population had no depression symptoms. This has gone down to about 45% of the population during COVID, with all of the clinical levels – mild, moderate, severe levels of depression – increasing. So there really has been a whole-population increase in depression – so not just of, you know, diagnosis of, like, major depression, but just of depression symptoms.

So this kind of anecdotal thing you’re experiencing where you might be feeling and people you know might be feeling like – just not feeling great, we see this in the data. And what might we see going forward? Well, although we’ve never had a global pandemic before – or we haven’t had one for a hundred years, we do have data from other parts of the world that have had epidemics. So these are data from Sierra Leone, where a study was done a year after the Ebola epidemic. And what the – what folks found was that, really, if you look at the – if you look all the way over to the right, over half the population was still experiencing some clinical levels of depression, anxiety or PTSD. So not only during the epidemic of Ebola did people see this, but a year later, after it had ended, these symptoms had persisted. The other thing we know is that the mental health effects of COVID are socially patterned. And Dr. Shim’s going to talk about this, I think, in more detail, so I’m just going to touch on a couple points here. So just like the virus – the effect, impact of the virus has disproportionately affected certain communities, social factors also influence who has mental health effects of COVID. And one of the biggest ones is the economic consequences of COVID really adversely affect people’s mental health, and this has real implications for what should be done.

So this is just one paper that we did after the 2008 Great Recession. And there are a number of papers like this. So we showed that home foreclosure during the recession was associated with increased risk of depression, anxiety in people who had been mentally healthy before. That is, losing your home, losing your job increases risk of mental health problems. And so we would expect these economic consequences of the COVID shutdown to have lasting adverse effects on mental health. And are we seeing this? So I’ll just give you a couple examples. So these are data from England, and the kind of bluish-green bars are baseline in 2019, and the burgundy ones are during COVID. And you can see that if you look at levels of anxiety, it’s increased across the whole chart. However, you see the biggest increase in the low-income groups. People making 10,000 pounds or less a year – the biggest increases of anxiety. So the burden of COVID is really felt more in these lower-income groups. And on top of that, we would expect the burden of COVID in terms of mental health to be felt more among people who have other stressors as well. So this webinar focuses on COVID, but there’s been many other social stressors during the past year. There’s been the murder of George Floyd. There was the insurrection in January. There’s been a lot of political unrest. And we would expect those factors to also contribute to negative mental health.

These are data from Hong Kong, and these show two things. One, if you look at the striped versus the red bar, the red bar are people with low assets, meaning lower income, and you can see, across the board, people with lower income are showing higher depression during COVID. But you also see that people who experience high COVID stress plus high unrest stress related to the political turmoil in Hong Kong have the highest depression. So we would also expect to see that in the U.S. I haven’t seen data on this. I expect, you know, people are probably writing up these papers right now, and they’ll be coming out. Finally, before I end, I just want to say that mental health is the foundation of all health. So while we focus – this webinar’s on mental health; mental health really is the basis of health across the life course. And we really need to end this – 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. And I’ll just show you a little bit of data from my own group. We’ve been studying this for many years. And so, for example, here’s data showing that women with higher PTSD symptoms were at increased risk over their lives of diabetes.

We’ve shown the same thing with cardiovascular disease and stroke. This is a slide showing that women with depression and PTSD have increased risks of – not just of, you know, these physical health problems but of cognitive decline as they age and that the effects of PTSD and depression on cognition, like learning and working memory, are bigger than increasing age in itself. So these mental health problems really have this toxic effect in terms of cognition. And finally, the sort of maybe most sobering evidence is that people with mental health problems have increased risk of early mortality. And again, in the cohort we study, we’ve seen an almost fourfold increased risk of early mortality related to depression and PTSD. So we need to address mental health not just because people are suffering now, which is a good reason in itself, but because we will feel the adverse effects of mental health across – both across the life course and across generations. To end with some resources, people are welcome to go to our website – I’m sure the other speakers have resources too – where we’ve talked about this REACH approach for mental health during COVID and have a number of resources available. I’m happy to answer questions about that. Thank you.

[0:12:18]

RICK WEISS: Thanks, Karestan – some really interesting data there, and I want to remind our reporters on the line that all these slides will be posted on the sciline.org website at the end of the briefing. And a transcript will be arriving a day or two after that so you can spend more time looking at some of these figures and getting down to the numbers. So next, we’re going to move on to kids a little bit and – with Sheri Madigan.

[0:12:44]

SHERI MADIGAN: Hi. So thanks so much for allowing us to come here and talk a little bit about our data. So if you’re a parent or you’ve talked to a parent over the last year, you know that it’s been a really incredibly challenging time for both parents and, really, for their children. From social isolation at home, school closures, balancing, you know, working from home and home-schooling and, for some people, dealing with job loss has created incredible stress for families. So what I’ll talk to you about today is just some data that we have emerging from a cohort that we’ve been studying for the past decade or so. So we were able to look at how they were doing before the pandemic compared to how they’re doing during the pandemic. So as was just mentioned, you know, mental health difficulties are often thought of and examined by looking at depression and anxiety. And I just put a little bit of a definition here, but typically, these are assessed using self-report measures, certainly in longitudinal cohorts with lots of participants.

And as was just mentioned, you know, COVID is really a perfect storm for why we might see increases in mental health difficulties because it’s been so difficult with all the changes, obviously, and so much increased stress. And I think that we’re seeing a lot of negative psychological symptoms associated with that – associated with COVID, like our stress, loneliness, but also the removal of a lot of our social supports that we used to rely on quite heavily. So for parents, that might have been relying on grandparents to help them, you know, with child care pickup or whatever it might be, and a lot of those supports were actually removed. And they were caught in a generation where they were worried about the older generation in terms of taking care of their family members, their parents, but also worried about a younger generation, worried about their own kids – so really in a sandwich generation of and surrounded by stress, essentially.

So in our study – it’s called the All Our Families Study, and we’ve been following about 1,500 moms for the last decade or so. And the children in our sample are now 9 to 11. So moms were pregnant when they started with the – as participants, and as I mentioned, we’ve been following them almost annually for the last decade. Our sample is – here’s just a bit of demographics. And I’m happy to talk more about these in the Q&A. But just to give you a little sense of what the demographics of this sample are, the – these – the families that are in our study reflect the parenting population generally in Canada. And we collected data on COVID-related stresses about three to six months into the pandemic. So it was May, June and July of last year. What you can see is that even – you know, in our sample, they experienced a lot of pandemic-related struggles and stress. So 60% had lost some type of income due to the pandemic, 43% told us that they were struggling to meet financial needs, and 5% had food insecurity. And about 78% of the moms in our sample were saying that they were really struggling with that juggle of home-schooling, working from home and also the domestic responsibilities. So that was a big – pretty significant stressor for a lot of them.

So I’ll just talk really briefly about maternal mental health during COVID. So one of the advantages of having a longitudinal cohort is that you’re able to more precisely estimate shifts in anxiety and depression symptoms because you can compare how families are doing during COVID to how they were doing before. And what this graph is just showing you is when kids were 3, 5 and 8 years of age – and you can see below what years of data collection that was – about, you know, 12 to 19% of the moms in our sample were saying that they were struggling. But what you can see in terms of their anxiety and depression is that – what you can see is that during COVID, so when these same children were about 9 1/2 years of age, we basically saw a doubling of both anxiety and depression during the COVID time point. So – and the second thing we really looked at is what was sort of – what was predicting these increases in maternal depression and anxiety. And we looked at a variety of different factors. And the ones I have here are sort of the strongest predictors that really suggested that. We saw especially high increases in families that were having a really hard time balancing the demands of home-schooling, working from home, domestic responsibilities. When families lost child care, this was also associated with increases in depression and anxiety, and then when they were – had suffered a job loss of some sort.

And then in terms of child mental health difficulties during COVID – so to curb the spread of the COVID-19, obviously, lots of changes were imposed in families and in children, and this has definitely impacted kids’ daily routines and functioning more directly. And we know that that can be a precipitant to some mental health challenges. And what you can see – this isn’t our data but data that’s in the literature right now. In the red bar are estimates pre-pandemic of depression and anxiety, and it’s about 8.5% of kids are struggling with clinically significant anxiety, and about 11.5% have clinically significant depression. And I’ve just listed three studies here, and they reflect different age groups, but what you can see is that there’s been quite a substantial increase across all age groups but especially in tweens and teens in terms of their mental health during COVID, with almost half of middle child – sorry – tweens and teens telling us that they’re really struggling with their mental health. These are all North American samples as well. One of the things that we were interested in is, what is predicting children’s anxiety and depression during COVID?

So we looked at child-reported anxiety and depression, and we know that this can be predicted by lots of different factors, both individual child factors, but also parent factors like the parent’s own mental health. What we found are the most potent predictors – sorry – are that children’s preexisting, obviously, anxiety and depression. So that’s going to be a very consistent finding in the field is that children who were struggling with their mental health prior to the pandemic are struggling during the pandemic. But we also found that kids – these – a lot of individual factors for kids are really what was predicting their anxiety and depression during COVID. So if they were feeling disconnected to their family members, they seemed to be struggling more in terms of their mental health difficulties during COVID. If they had increased screen time during COVID, and if they had reduced sleep, these were also associated with their anxiety and depression during COVID. So these were the significant predictors over and above their previous mental health prior to COVID. So one of the things – and I’ll end here – is just that there’s been a lot of discussion about the fourth wave of the pandemic.

We’re currently in the third wave here in Canada, so it’s been titled the fourth wave. And this was just a – you know, something that came out right at the onset of the pandemic, actually, was just saying that the fourth wave is going to be a mental health wave. And I – you know, we just talked about that in the previous presentation. This is likely going to be a very significant consequence of the pandemic that we’re going to have – see mental health difficulties, and that is likely to be sustained over time. And we’ve already seen that in our clinics. And as a clinical psychologist, I can say we’ve seen an influx in referrals and children needing mental health treatment. So we’re seeing that, and we need to start to plan for that. So I think one sort of take-home message for me is that we really need to start thinking about this fourth wave or this mental health wave that’s likely to be sustained over time and to start to put things in place for kids so we can – and parents so we can help sort of really start to think about and help with post-pandemic recovery planning. So these are just some acknowledgments of our funders, and I look forward to taking your questions in the Q&A.

[0:21:17]

RICK WEISS: Thank you, Sheri – a very interesting and sobering look in that final fourth wave graphic. And with regard to questions, a reminder to reporters – you can click – hover over and click on the Q&A icon at the bottom of your screen if you want to preload some questions for our panelists. And we’ll move now to Ruth Shim.

[0:21:38]

RUTH SHIM: Thank you. It’s so great to be here with all of you, and I’m really excited about the idea that my topic builds so well off of the presentations that Dr. Koenen and Dr. Madigan just shared with you. So I really want to kind of put together how mental health inequities, structural racism and COVID-19 kind of joined together to create a bigger problem that we need to address. So what’s interesting about mental health and psychiatry is that we’ve often spent a lot of time thinking about the biopsychosocial model. And in the last 40 or 50 years, we’ve spent most of that time really focused on the biology, thinking about mental health as a brain disease, thinking about how certain neurotransmitters and aspects of brain health affect mental health outcomes. 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 aspects. And what we know and what we’ve heard in these previous presentations is how much social factors have an impact on our mental health outcomes, and I’m going to highlight that. But first, we need to define a topic, a couple of concepts, and one of them has to do with this concept of health disparities.

So health disparities are defined as differences in health status among distinct segments of the population, including differences that occur by gender, race, or ethnicity, or education, or income, or disability or where you live. And that’s very different from this concept of health inequities. Health inequities are disparities in health that are the result of systemic, avoidable and unjust social and economic policies and practices that create barriers to opportunity. It’s really important to contrast these two definitions because health inequities is really saying where the difference is coming from and that it’s the result of these systemic, avoidable and unjust social and economic policies and practices. The health disparities definition is just describing the difference, but it’s not really saying what the cause of the difference is. And so if we don’t know what the cause is, we have this unfortunate tendency to kind of seat the pathology or the problem in the individual or in that particular population. And so we’ll say maybe there’s some sort of biological reason why there are differences, or maybe there is some sort of cultural reason; there’s decisions that this particular group makes that are different from the groups – other groups, rather than recognizing that there is this host of systemic, avoidable and unjust social and economic policies and practices that are really responsible for why we see differences in mental health outcomes among different populations.

And so that gets us to this definition of the social determinants of mental health. These are the societal, environmental and economic conditions that impact and affect mental health outcomes across various populations. And these conditions are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. And the social determinants of health are prominently responsible for the health disparities and inequities that we see among populations. So what this definition is basically saying is that our opinions, our social norms, our ideas that we have about certain people lead us to create policies, to pass laws about how we feel those people – whether they are worthy of certain advantages in our policy structure or disadvantages. That leads to an unfair and unjust distribution of opportunity, and then that creates a number of social determinants of mental health. And those many social determinants include things like adverse childhood experiences and interaction with the criminal justice system and discrimination.

It has to do with poverty and housing insecurity and unemployment, as well as climate change and differences in exposure to greenery and the built environment in your – in differential neighborhoods. All of those things create risk factors that then lead to poor mental health outcomes and then inequities in outcomes. So that’s discussing mental health inequities. And then to briefly define structural racism, that is a system in which public policies, institutional practices, cultural representations and other norms work in various, often reinforcing ways to perpetuate racial group inequity. And we’ve seen many examples of how structural racism impacts health and mental health, including things like redlining and how that leads to access to clinics and – as well as immigration policies. Specifically, I want to take some time to talk about this research that was conducted looking at differences in depression symptoms both before and during the COVID pandemic.

This was work by Ettman and colleagues, and they noticed that there was a rise in depression rates across racial and ethnic groups for differences in the COVID – during the COVID pandemic. Interestingly enough, that rise in depression rates was even higher for Asian populations, possibly due to discrimination that they experienced. I wrote the accompanying commentary to this article, and one of the things I pointed out in that discussion is that 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 health care. So if we are going to effectively address the social determinants, if we’re going to address this increased prevalence of depression and other mental health problems, we are going to have to focus on the social determinants of mental health. This is a little bit of data looking at age-standardized mortality rates by race and gender. This is data that’s available in Michigan because we don’t have a lot of data to support – data on a federal level. But what you see is that generally there are higher rates of mortality associated with COVID for men than women.

But we have to take into consideration that there is a risk of intersectionality. So while men are more likely than women to die from COVID, intersecting identities put oppressed and minoritized populations at greater risk for mortality. And so what you see is this collection of conditions into what is called or termed a syndemic or a synergistic epidemic. And so you see mental health inequities, structural racism and COVID-19 coming together to create a perfect storm. So it is the concentration and deleterious interaction of two or more conditions in a population, especially as a consequence of social inequity or the unjust exercise of power. So in syndemics, the interaction of diseases or other health problems commonly arises because of adverse social conditions that put socially devalued groups at heightened risk. So if we’re going to address this, we have to get down to fixing or changing our public policies and changing our social norms or our beliefs about people and populations.

And we can think of countless examples of populations and people and individuals who as a result of the COVID pandemic may have lost their jobs. That pushed them into poverty, into food insecurity issues, into problems securing housing. That increased risk put many people at risk of developing depression. And then with that depression, without insurance, health insurance, people have difficulty accessing care. So I have a number of recommendations, but we don’t have time to go over them in detail. So I’m just going to leave them here, and we can discuss them further in the Q&A, but it involves engaging and empowering communities, expanding insurance coverage and access to care, and improving data collection and dissemination. And I’ll stop there.

[0:29:58]

RICK WEISS: Thank you, Ruth, for a really important perspective on what’s going on with mental health. I wonder if one thing that will come out of this pandemic is a broader recognition that mental health issues are not just neurological issues to be dealt with with a pill or even with therapy but with societal attention on them. And I really appreciate and I think reporters should take to heart the difference between disparities and inequities – a small change in language that really makes a difference. So I want to move into the Q&A here. I see some questions coming in. Please hover over Q&A to submit your own. But I always start these briefings with a question for each of our panelists first. Just some professional advice for the reporters online, whether there’s something that you can point to that you either think has been really good that you’ve seen reporters doing as they cover this area in their journalism or something you wish they would do differently or a little bit better. And let’s just go through the three of you first for any quick hits on, you know, what you think journalists online can be proud of or maybe should be changing a little bit as they do their work on this beat. And I’ll start with you, Karestan.

[0:31:09]

KARESTAN KOENEN: Sure. Thank you. So I think a positive I’ve seen is just the number and the extent of journalistic interest in the topic of mental health in all aspects of it, from, you know, the more clinical aspects to the more social aspects of serious mental illness. So that has been really – I think that reduces stigma, just talking more about it. The negative I’ve seen – and this is not maybe just about mental health – is that fear drives – fear sells papers or whatever. Fear gets attention, but fear is toxic to mental health. And the sort of media onslaught of fear-based headlines in journalism is a contributor to adverse mental health, and that is something that – I’m not a journalist, so I don’t know how to address. But I do think that that has been problematic across the coverage of COVID.

[0:32:05]

RICK WEISS: Thanks. Sheri?

[0:32:08]

SHERI MADIGAN: Yeah. I don’t have much more to add other than that. That was so nicely summarized. You know, I think that if we can – I do think that the more we can talk about this, the more we might get some advocacy and some attention from policy makers. And I do think that we need to start thinking about the long-term consequences and the mental health impact, and that this is likely to be sustained for quite some time, especially given the doubling we’re seeing across all populations. So we saw it across – this isn’t just, you know, about kids. It’s not about just health workers. It’s not about just parents. It’s general population. It’s everyone is really struggling. And so I think some more attention to that and understanding that this has been an incredibly difficult time. And I guess I could just speak to moms in saying, because we study moms, that, you know, moms, we tend to think of them as having some superpowers.

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. And what we – what the consequence of that is, is obviously some impact on children’s mental health, too, so it becomes a family affair. So I suppose just doing more of the great work that they’re doing. I know it’s probably been hard on journalists to be working around the clock as well. And if we can get some positive news stories out there – you know, there’s been a lot of people who have really stepped up and helped families. And if we could talk about those positive news stories, that would be great as well.

[0:33:43]

RICK WEISS: Cool. Ruth?

[0:33:44]

RUTH SHIM: Yeah. I think that reporters have done a great job of getting this concept that social factors are, in fact, very related and relevant when thinking about mental health outcomes. And so I do commend journalists for doing great work in that space. And it relates to my presentation. The area that I think that more work could be done has to do with thinking about what the origin of differences might be. And so I’m still seeing a lot of journalists highlighting or putting the onus on the individual rather than looking at the structures that are causing those differences. So just a very quick example – there is a lot of discussion around how certain communities are very vaccine hesitant.

And so the reports are coming out that say that Black communities have higher rates of vaccine hesitancy. But there was a recent study that just came out that showed that due to structural racist policies like redlining, people that live in predominantly Black communities have to travel significantly farther to get to a vaccination site than somebody who lives in a predominantly white neighborhood. So there you have a structural explanation for why you have different rates of vaccination between groups. I mean, it’s not necessarily driven by the opinions of Black people, or the idea is that Black people are more hesitant to get vaccine, but a real structural issue of people cannot get to the places where vaccine is being delivered.

[0:35:18]

RICK WEISS: Great. Thank you all. We’ll start now with some of the questions we have here. And I’m going to start with a question from Cindy McCormick from the Cape Cod Times, and she’s asking whether raising awareness of the risk of PTSD, even as the pandemic hopefully is ebbing – will that help people who are continuing to struggle? Will raised awareness help people? Will it normalize their pain and encourage them to seek help? And what are the most effective tools to combat depression and PTSD during a pandemic? Someone want to raise their hand to maybe start answering that? If no one volunteers…

[0:36:03]

RUTH SHIM: I’ll take a stab at that and just say that raised awareness is always good. And so the more people know that there is a risk of trauma and post-traumatic stress disorder associated with the COVID pandemic, the better that is in terms of normalizing. I think that one of the biggest challenges around trauma or all mental health problems is this feeling that people feel very isolated. They feel very alone. They don’t always feel that other people are experiencing the same things as them. So I think it’s very important to raise that awareness. But then just as important as raising the awareness is making sure there are services in place, making sure that there are mental health providers, community members that can help people get into care and so help people access care, whether that be through neighborhood organizations, or through churches, or through psychiatric care or primary care providers. But the connection needs to be made so that the increasing awareness then leads to more people seeking care.

[0:37:16]

RICK WEISS: Sheri, you’re a clinical psychologist. Maybe you can add to the question of what can be done. What helps?

[0:37:24]

SHERI MADIGAN: Yeah. Well, I think that one thing to add, which came in Dr. Shim’s presentation, is it’s not just on – incumbent on the individual to always seek care, too. You know, I think the more that we talk about mental health or mental illness in a way that destigmatizes – but also in a way in which policies are supported so that people can feel like they can get some mental health support. That may be, for example, flexible leave policies at work. So I get – some of the – I’ve been sometimes asked, like, you know, what’s a – what more can we – what more can moms do or what more can parents do? And I said, well, let’s not add to their juggling act. Let’s actually try to get some of the policies of that structure around them to create some support. So we know that there’s going to be more sharing of home-schooling responsibilities with both parents – when both parents have flexible leave policies, for example, and can restructure their day to accommodate kids.

So rather than always turning it over to the individuals to seek help or the individuals to reach out, like, I think we can also look at what’s around them and encourage workplaces, for example, to send out information about, you know, where they might be able to get some services or, you know, have governments make changes, too. So I’m obviously a psychologist, and I see people individually. And I think it’s important to attend to people who come to us because they have mental distress. But I think that if we change the systems around the individual, we’re also going to see that people will feel less stigmatized and perhaps will feel that normalization process that the reporter asked about coming forward. Yeah.

[0:39:13]

KARESTAN KOENEN: And I think just as along those lines, you know, structural problems need structural solutions. And I do a lot of things. Like – so workplace is one I’m sure Dr. Shim might even have done the same thing – want awareness, want seminars. But you can’t just talk. You can’t just have people come in and talk about their problems. There’s – there is a obligation for institutions to create policies that will support workers’ mental health. And similarly, as – in – at the government level, economic policies that keep people in their homes, support people’s jobs, make sure they have food are mental health interventions. And they are the most fun – the most – one of the most fundamental human needs are food, clothing and shelter. And if that is disrupted, getting everyone an individual therapist isn’t going to solve the problem. So I think we’re all saying that structural solutions are needed.

[0:40:11]

RICK WEISS: Great answers, thank you. The next question here is from Elizabeth Miller. She’s from the Auburn Examiner in Washington. What has data shown regarding suicide and/or addiction relapse during the pandemic? And what steps, if any, have been taken to address any increases found?

[0:40:31]

KARESTAN KOENEN: I can speak a little of that. Maybe – so I had looked at the suicide for the – I had looked at some of the data on suicide. And I think it’s been complicated, I guess, is my read. And I don’t know what doctors you met. It’s been complicated. There’s been some studies that have shown no increases. There’s been some that showed declines. And then there’s some evidence in Japan that there was an increase. So it’s been complicated and not simple. And suicide is also a complicated problem. I think the data is more consistent in showing that people have increased substance use and relapse during the pandemic. Of course, it depends on the substance. But that seems more consistent. I don’t know what other colleagues would say.

[0:41:16]

SHERI MADIGAN: Yeah. I don’t have anything else to add. I’m actually not as aware of that data.

[0:41:23]

RICK WEISS: I would encourage reporters to look back at our previous media briefing we did on cannabis use, which did address a little bit the question of increased use of at least some drugs during the pandemic. Question here from Carter Barrett from WFYI Public Radio in Indianapolis – I’ve been working on stories about how difficult it can be to access mental health care, but I don’t want to contribute to a feeling of hopelessness in people seeking care. Do you have any advice? Thank you all for sharing your insights. It’s a bad-news story. It’s hard not to contribute to it.

[0:41:58]

RUTH SHIM: I was going to say, you know, I think it unfortunately needs more exposure. I think that the – again, it’s a structural problem. And so we need structural solutions, which means we need to transform and address and restructure our mental health care delivery system. It’s hard to get around to putting a positive, nice spin on that. It’s really kind of – we’ve gotten to an extreme case and COVID has made that very clear to us that we are already working with an inadequate system. And now COVID has kind of exposed those inadequacies. So I unfortunately have no positive statement to make on how to put a hopeful spin on this. This is one of these situations where this is a syndemic and it’s bad. And we have to change things. We need to make some dramatic changes.

[0:43:03]

RICK WEISS: Question here from Molly Longman – she’s from Vice Media. I’ve been seeing some reports, such as a JAMA Psychiatry study, that talk about how COVID-19 – and I think she might mean the virus itself; I’m not sure – may be impacting the brain and contributing to mental health impacts such as depression, anxiety and even instances of – or suicide. How do we cover this in context, given that mental health is so wide-reaching and so many factors are involved? How do you cover a study like this without fear-mongering? Any evidence about…

[0:43:42]

KARESTAN KOENEN: I feel like I should address it, since I brought up the fear-mongering and now I don’t have – so I think it’s a challenging topic because I think there is evidence that the COVID infection itself affects mental health. And Dr. Shim may know more about that. And also, I mean, I personally know people who have PTSD from having COVID in the sense that it was such a traumatic experience. So there’s that piece, too. So, you know, again, is there – what is the – I don’t know that there’s a positive spin on that story, except I think addressing some of the things we’ve said that the broader context of mental health issues, what the general prevalence is of problems versus in COVID and maybe in emphasizing some of the things that we do know, and we need to learn about it. But I do think – yeah, I do think it’s challenging. I don’t have a solution. Maybe one of my esteemed panelists have something better to say.

[0:44:43]

RUTH SHIM: Yeah. I would just like to add to that. That – so again, it is always this intersection between biological, psychological and social. And so, yes, I am aware that there is new data showing that the COVID infection does have impacts on the brain. And we do know that mental health problems are brain diseases and, therefore, there are some interactions and some changes that happen in the brain that will increase the chance of mental health problems associated with COVID infection. However, again, I think we sometimes overemphasize the biological piece and don’t necessarily emphasize the social impacts. And what I think is if there’s one tiny little piece of hope in all of this very depressing conversation, I think that small little piece is that social factors are the ones that we can change. We can mediate those. We can actually intervene on those things very quickly and very effectively. And so, yes, I do think it’s important to share that information, but also to highlight and talk about how there are other aspects that have just as much influence on the development of mental illness. And those are the things that we actually have control over and things that we can actually put systems in place to prevent and do less harm.

[0:46:10]

KARESTAN KOENEN: And just along the lines that Dr. Shim reminded me to say that even illnesses that are – have a lot of biological drivers, such as, let’s say, schizophrenia, which definitely has a big biological component, some of the interventions that can be incredibly helpful are psychosocial. It’s not beyond medication. So even if COVID infection itself has an effect on the brain that’s manifested in mental health, it doesn’t actually mean the social interventions or the psychosocial support, et cetera, could be the answer to that. So that is – I think that, you know, that’s important. It’s a really good point that she had been making.

[0:46:53]

RICK WEISS: Question here from Christine Herman from Illinois Public Media. This may be for you, Sheri. Given the severe shortage of mental health providers for kids, what can realistically be done to meet the increased need in the short term?

[0:47:12]

SHERI MADIGAN: Yeah. And there’s a question above that that’s around like how do schools use pandemic funds to provide services? So I think I can actually blend these two together. The reality is that a lot of kids actually get their mental health services in school. So if kids have been offline or sorry – they’ve been out of school and online, it’s possible that they haven’t been getting their mental health services. So a lot of kids will do, for example, group-based treatment or they – you know, many schools have a psychologist and kids will see them. So that hasn’t been as accessible. Although I will commend many, many therapists for moving onto telehealth and doing that quite seamlessly. And there’s been a big buy-in to tele-mental-health in the last year. But I think in the short term, what I would recommend schools do, because they can address them a bit at that sort of – they’re – they can help families in a variety of ways. I think that they can make telehealth accessible. So if they haven’t moved on, you know, therapeutic services to online, I would strongly encourage they do that so kids can get some accessibility to some treatment.

And then I think that schools can share resources that are out there. And if they – one of the questions, if they have funds, what do they do? You know, I think they could host webinars, for example, to parents or to the kids. And an easy one, for example, would be about routine. So there’s been some great research to come out showing that when route – when families are using routines, even though the pandemic has been hard to maintain routines, especially when kids are at home, but when sleep routines, screen routines and school routines are consistent, kids are doing better during COVID. So there’s some small things around trying to get families back on track in terms of establishing routines that could be really helpful. And that could be distributed, for example, through the school in a webinar, perhaps – hopefully with a psychologist or clinician on board to help with that. So I think some small things that schools could do is reach out to families. Be part of their community. Stay engaged with them and offer as many resources and supports as they can to help families in need.

[0:49:27]

RICK WEISS: Great. And I want to acknowledge Kent Jackson from the Hazelton Standard Speaker in Pennsylvania for that school question that you addressed. There’s a few questions here that all fall under the umbrella of sort of solutions journalism, I’d say, and looking at actual potential solutions. Christine Herman back at Illinois Public Media asking if there are examples of states doing a good job of pursuing structural solutions. We have Hannah Furfaro from Seattle Times asking about structural solutions you might have heard of at school districts or elsewhere that are working or legislative solutions that are out there, and Alexis Wnuk from brainfacts.org asking some similar questions. Why don’t I just go through each of you to see, you know, what kind of positive examples of solutions you might be able to bring up? Karestan, you want to go first?

[0:50:25]

KARESTAN KOENEN: Yeah. I guess the ones that I’ve seen are any of the economic interventions which have varied from town to state and then there’s federal that have, again, like, protected people in their home, provided income, extending unemployment benefits. And then also there’s been a big step up, I can say, in my own community in Massachusetts, for example, of the city of Boston gave everyone meal vouchers. You didn’t have to apply for the meal. It was just automatic. You have to opt out. Brookline High School, which is near where I live, every Friday has groceries out there. You don’t have to – anyone can walk up. They’re for the community. But doing – so there’s been a number of things like that on the economic side, which I keep saying because those things do help protect people’s mental health and support their mental health. And so that’s what I’ve seen. I’m less aware on the, like, mental health side specifically, so maybe my colleagues can talk about that.

[0:51:25]

RICK WEISS: Sheri?

[0:51:26]

SHERI MADIGAN: Yeah. So, like, in going – I totally agree with what was just said. And in going along with that, we’ve been talking about, like, various layers of the child’s, like, ecology and what matters for kids. It’s not just their parents, but their communities and the – you know, where they live and how they’re doing and community support. So I would just say one of the – a touch point for a lot of families is pediatricians or family physicians that they see. So if there are family physicians out there, I guess knowing that one of – that they are one of the few touch points for a lot of families. And I think it’s really important to start to check in with families about how they’re doing from a mental health perspective. And that can be as easy as just saying, how are you doing? You know, and I think that’s really – can be really helpful or even normalizing it for families by saying, a lot of families are really struggling. How are you doing?

So people can actually know that they’re not alone. I think that’s really important. And then – and we’ve just talked about policies and then obviously sort of physicians who are helping take care of families, but I think we can all do an individual-level impact. So we’re all really tired, obviously. There’s a lot of burnout going around. But I think at an individual level, we can check in with the people around us, and we can encourage people who we know are struggling to reach out to us when they’re distressed and have a plan for how we might be helpful. So I think we can do – now that sort of some of the fear of the spread of the virus is dissipating, I think we need to actually be good community members and reach out to our people and the people around us and see how people are doing and sort of provide this social support that a lot of people are needing. If people have the energy to do that, I strongly encourage them to do so.

[0:53:20]

RICK WEISS: Ruth, what do you see in the solution space?

[0:53:23]

RUTH SHIM: So I definitely agree with everything that’s said, and particularly Dr. Madigan is kind of talking about this concept of collective efficacy that Mindy Fullilove has really helped to promote. And just at the neighborhood level, people coming together – that is hugely protective for mental health. And so I think we need to use more examples of developing and creating communities in which collective efficacy is at play. I think a very clear example where incredible – we’re seeing incredible outcomes is purpose-built communities, which is this concept in which, you know, community members have gotten together and kind of restructured and reformatted neighborhoods to create better educational systems, to create affordable housing, affordable access to food. It involves community members being part of the policymaking process for those neighborhoods. And the outcomes are incredible in terms of overall lower rates of mental health problems and physical health problems and general positive outcomes. So there are examples like that for almost everything. I think, you know, for each one of the social determinants, you – people have – especially individuals in their communities, have come up with solutions to these problems. But it’s really a matter of kind of bringing those solutions to scale.

[0:54:54]

RICK WEISS: Just want to say, I really love the way this briefing has come full circle. You talked all at the beginning about all the different things that contribute to mental health, and I think that really helps to answer this question at the end to remind folks that the solutions to some of these mental health problems are not just the things we often think about as mental health solutions, like therapy or drugs. But it might be providing day care. It might be providing food. It might be helping with housing. It’s a really important breakdown of, I think, conceptual barriers that you folks have helped bring to light today. We are just about at the end of our hour here. And I do want to end with an opportunity for each of you to go around and just offer the reporters online a take-home message.

Maybe it’s something you’ve said; maybe it’s something you haven’t, that if they’re going to walk away with one important truth from today’s briefing, what would you prefer that to be? And as we prepare to do that, I want to remind the reporters who are on the line as we wrap up today that when you do log off, you will see a small three-question survey in front of you. We all hate surveys, but those of us who give them really need the data, could use the data to help us keep these briefings working for you as best as possible. So I really encourage you to take the 30 seconds to do that. And let’s go around the horn and get some final comments from each of you, starting with you, Dr. Karestan Koenen.

[0:56:16]

KARESTAN KOENEN: Thank you. So to – I guess what I would like to leave with is where I ended my presentation, which is that mental health is the foundation of all health, and that by supporting as a – 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 that would actually be transformative for health broadly.

[0:56:42]

RICK WEISS: Fantastic. Dr. Sheri Madigan.

[0:56:47]

SHERI MADIGAN: I think that – I suppose a very important takeaway is that we’re seeing mental health struggles and difficulties across all populations – so parents, adults, children. There is a huge wave of mental health struggles here, and it’s likely to be sustained. So I think we need to really start to think about these various levels and how we can make some modifiable changes to start to improve the wellbeing and the structural supports of families because – and all individuals ’cause people are really struggling.

[0:57:25]

RICK WEISS: Thank you. And Dr. Ruth Shim.

[0:57:28]

RUTH SHIM: I think – I cannot remember who said it, but somebody said that all policies are health policies. And I think that, by extension, all health policies are mental health policies. And so when we think about solutions to how to address mental health problems in the age of COVID, we need to think about all policies and bring all policies on deck to solve this mental health crisis.

[0:57:56]

RICK WEISS: Fantastic. I want to thank our panelists so much for a fascinating and fact-filled, research-backed presentation on this important topic. Thank you, reporters, for joining us and for doing the work of covering this topic. This briefing will be on the sciline.org website soon for you to refer to. I encourage everyone to follow us on Twitter – @realsciline. Fill out the survey, and join us for our next briefing. It will be marketing to you soon. Thank you all very much for being part of this today. So long.