By Sandro Galea and Catherine Ettman
Since the earliest days of the Covid-19 pandemic, this crisis has posed challenges for mental health. As of April, 2020, stay-at-home advisories or shelter-in-place policies affected no less than 316 million people in the US—about 96 percent of the population—making sustained social isolation, for perhaps the first time in the country’s history, a ubiquitous experience. We have for months been physically cut off from family and friends. We have had to learn new ways of interacting, new practices for safeguarding health. Many of us now have had personal experience with the virus, either by contracting it ourselves, or knowing someone who has. Some mourn the loss of loved ones, and we all mourn the thousands who have died from this disease in the US and around the world.
These challenges—the virus itself and the policies we have adopted to contain it—have created a perfect storm for poor mental health. This was reflected by a recent report from the Centers for Disease Control and Prevention, which found during June of 2020 adults in the US reported considerably elevated adverse mental health conditions linked with the pandemic. In particular, racial/ethnic minorities, essential workers, unpaid adult caregivers, and younger adults reported disproportionately poorer mental health outcomes, including elevated levels of substance use and suicidal ideation.
Now, we are starting to see how these conditions are increasing depression in the whole population. In our new JAMA Network Open study, we found that the prevalence of depression symptoms in the US were more than three times higher during Covid-19 than before the pandemic. We conducted a nationally representative survey study, which engaged with two population-based surveys of US adults. We evaluated these surveys by looking at stressors which, based on prior studies of traumatic events, we know contribute to poor mental health after such occurrences. These include factors like job loss, financial problems, and a close friend or relative dying due to the pandemic. The collective trauma of Covid-19 is reflected in these stressors unfolding in the lives of individuals, rippling among social networks, to shape the health of the entire country. Their influence created a circumstance unique in recent history, in which whole populations faced levels of stress acute enough to account for such a significant rise in depression.
But while Covid-19 was a relatively sudden shock, its psychological effects were amplified by conditions in the US which long predated the pandemic. Covid-19 unfolded in a very specific context, one shaped by demographic factors like education, income, and race/ethnicity. These factors matter for our health at all times, and especially in moments of challenge. The work of public health is, in large part, the study of this influence. Those who make more money, who have more education, who do not face marginalization and discrimination on account of race tend to have better health. Our research found these factors were key to shaping depression risk during the pandemic, with groups with lower social resources experiencing greatest risk. Even as depression risk rose across demographic categories during Covid-19, risk remained higher for the groups facing disproportionate vulnerability before the pandemic struck. For example, prior to Covid-19, women were likelier than men to suffer from depression. This remained true during the pandemic, even as risk rose for both groups. We also found that greater exposure to pandemic-related stressors meant more depression risk, as difficulties compounded to make the challenge of the pandemic far worse for many Americans. It is hard enough, for example, to cope with isolation and fear of the virus. Add job loss, lack of savings, and the sickness or death of a loved one to this, and we have a picture of the difficulty faced by many as this crisis has unfolded.
Of particular note in our study was the link between material resources and mental health. We found that during Covid-19 depression risk was linked with lower income. Having less than $5,000 in household savings was linked with a 50 percent greater risk of depression symptoms. This is consistent with the well-documented connection between money and the ability to live a healthy life. Money buys access to good schools, safe neighborhoods, nutritious food, and the flexibility and peace of mind that come with having enough in the bank. Access to such resources means that health outcomes vary significantly between those with more and those with less. Low-income populations tend to live shorter, sicker lives, with poor mental health a substantial part of that disease burden. When large-scale, traumatic events occur, the financial stressors they create can shape the conditions for mental health struggles, including increases in suicide, as suggested by our earlier research.
It is not difficult to see how Covid-19 intersected with financial instability, to undermine mental health. During the pandemic, having less money has meant less employment flexibility, with low-wage workers often having to face the stress of daily exposures at low-paying jobs to which they could not telecommute. It has meant fear of needing expensive medical care and lacking the ability to pay for it. This is to say nothing of how the pandemic, and the lockdown measures it necessitated, created a level of economic uncertainty comparable, by some measures, to the Great Depression, making even more unstable the already precarious financial position of millions of Americans.
If the weight of pandemic-related depression seems somewhat shocking, this is perhaps to be expected. We do not talk often enough about mental health. This has meant we have not yet fully faced the mental health consequences of the pandemic. Stigma and reluctance to regard mental health as on par with physical health enable this aversion, an aversion we can no longer afford. Unless we take steps now to mitigate the mental health costs of Covid-19, we place ourselves at risk for greater challenge in the present and potential catastrophe in the future. Preventing the worst-case scenario for mental health means, first, talking about mental health as the public health issue it is. It means pursuing policies which address the roots of mental illness; in particular, policies which help address the economic instability among US populations which does much to undermine both physical and mental health. In the near-term, it is important we address these economic challenges by making sure low-income communities do not face barriers to Covid-19 testing and treatment, which should be available to all, not just people with ample resources. Finally, it is important that those who suffer from mental health struggles know they are not alone, that help is available. This means continuing to put in place structures that enable populations to access counseling and treatment, so that no one must suffer in silence.
If you are experiencing mental health challenges, please consider calling the National Suicide Prevention Lifeline at 1-800-273-8255 for 24/7 free, confidential assistance. You can also text HOME to 741741 from anywhere in the US and Canada to communicate with a trained crisis counselor.
Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book is Pained: Uncomfortable conversations about the public’s health. Follow him on Twitter: @sandrogalea
Catherine Ettman is a doctoral student at the Brown University School of Public Health and director of strategic development at the Boston University School of Public Health Office of the Dean. Follow her on Twitter: @CatherineEttman