• Jason L. Fairweather, M.A. CMHC, Psychotherapist

Mental Health During and After the COVID-19 Pandemic

Today, the novel coronavirus, COVID-19, and the effects of quarantine are foremost factors relevant to our emotional and mental wellbeing. As we watched the pandemic unfold and people began voluntarily self-quarantining, which was followed in many areas by government leaders requesting or ordering self- and mass quarantine, the COVID-19 pandemic resulted in a worldwide mass effect, unparalleled thus far in the 21st century, on people’s emotional and mental health. In the span of four months, following the virus’s reported discovery in China, COVID-19, as of the date of this writing, has spread to 185 countries, infected 2,822,003 people, and has been a contributing factor in the deaths of 197,578 of those infected (Johns Hopkins University, 2020). During the previous four months, currently, and for an unknown period following the disease’s eventual decline, the mental and emotional health of those around the world are and will be negatively impacted.


What Are Epidemics and Pandemics, Exactly?


Before we get into mental and emotional health associated with the effects of this pandemic and possible methods to counteract them, let’s discuss epidemics, pandemics, and what history has shown us.


According to the Centers for Disease Control (CDC), the definitive difference between an epidemic and pandemic is as follows: an epidemic “refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area,” while a pandemic “refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people” (Centers for Disease Control, 2012).


What Do We Know From History About Viral Pandemics?


Between the 20th and 21st centuries, the world faced several epidemics and pandemics, most notably Polio, the Spanish Flu, the Asian Flu, AIDS, and more recently SARS, H1N1, Ebola, and the Zika Virus. Many of these viruses float(ed) the globe. With these viral epidemics and pandemics, we saw not only variations in methods of transmission but differences in the demographics of who was more prone to negative health effects post-transmission. For example, Polio affected mostly children; the Spanish Flu seemed in-discriminatory, infecting five hundred million people worldwide, resulting in the estimated deaths of fifty million of those infected, and nearly causing the extinction of various indigenous communities; AIDS seemed at first confined to the gay community but soon became known to be in-discriminatory with multiple sources of transmission. In the cases of SARS and H1N1, we saw very young and very late-adulthood individuals more commonly affected (Jarus, O., 2020; Centers for Disease Control and Prevention, 2013; Centers for Disease Control and Prevention, 2009).


Many sources have drawn parallels between COVID-19 and the 1918 influenza pandemic, which was coined the Spanish Flu, due to the speed with which the novel coronavirus has spread as well as its evident lethality. However, it is important to note differential distinctions.


First, consider the overall conditions of 1918 versus 2020: living conditions were crowded and cramped, making for easier transmission of viruses, especially in larger metropolitan areas; soldiers at war during World War I were living in cramped conditions, transmitting diseases amongst the troops and others abroad; domestically, hospitals were dealing with overcrowding due to soldiers returning from war while many doctors and other medical staff were abroad assisting in the war efforts, causing overcrowding in hospitals and a shortage of medical staff (Barberis, I., 2016; Terry, M., 2020; Youngdahl, K., 2018).


Second, in the early 1900s, there were no vaccines for the Spanish Flu, just as there is currently no vaccine for COVID-19; however, in 1918 there were also no antibiotics to combat underlying or secondary bacterial infections, which was cause for significantly higher rates of lethality. Given an inability of medical interventions in response to the influenza virus, that left only nonpharmaceutical interventions, such as social distancing, disinfecting, quarantine, and handwashing. While many researchers of the time struggled to develop vaccines for influenza and particularly the Spanish Flu, differences between bacterial and viral infections were unknown, leading to several ineffective vaccines that were developed to address bacterial infections. It wasn’t until the 1930s that researchers began to understand the differences between bacterial and viral infections; the first vaccine with any efficacy in preventing influenza was developed and licensed in the 1940s, more than twenty years following the Spanish Flu pandemic. (Barberis, I., 2016; Terry, M., 2020; Centers for Disease Control, 2019; Youngdahl, K., 2018).


How is COVID-19 Different?


A recurring topic, and hotly debated, I often see is how is COVID-19 different than, for example, SARS in 2002 and 2003 or H1N1 in 2009 and 2010? After all, both those viruses scaled from epidemic to pandemic.


SARS was quickly contained, effecting a substantially smaller scale of the global population. H1N1 was not so quickly contained; CDC estimates report that, globally, from April 2009 to April 2010, there were 60.8 million confirmed cases of H1N1 and 575,400 deaths (Centers for Disease Control, 2019). Inasmuch, aside from the specific strain of influenza, the defining differences between the H1N1 and COVID-19 pandemics are the speed with which the contagion of COVID-19 has spread—its rate of morbidity—and, more so, COVID-19’s evident rate of lethality. Within this vein, the CDC’s extrapolation data currently suggests that while morbidity of H1N1 may have been greater, the lethality-rate of COVID-19 has the potential to significantly exceed that of H1N1; this is to say, either fast-acting preventative measures have reduced the rate of transmission of COVID-19 or it otherwise may not spread as easily as H1N1. Extrapolated morbidity data appears to indicate COVID-19 has greater adverse health effects on certain demographics of those infected (gerontological patients and those with pre-existing medical conditions), causing greater needs for medical attention and rates of lethality (Centers for Disease Control, 2019).


Pandemics and Our Mental and Emotional Health


Globally, anxiety and depression are among the most common mental health disorders (Coughlin, 2012). Add a viral pandemic onto the number of stressors already affecting citizens around the world and we have a recipe for a mental health pandemic, as well.

The world economy stalled and then downturned; businesses shut down by order of local governments, putting small business-owners at risk and affecting those employed; people considered non-essential workers and unable to work remotely have found themselves without pay; those employees considered essential workers have found themselves on the frontlines of combating COVID-19 transmission; while gas prices plummeted, prices on other everyday goods, in various locations around the world, have soared; and, amidst all this, people are by order or choice self-quarantining and isolating. Furthermore, we have more specific examples, such as students being displaced from school; borders closing while loved ones are abroad; disrupted or depleted finances potentially leading to issues with meeting the basic needs of food and shelter. A list like this could go on infinitely.

Additionally, we have the internet and social media providing worldwide access to a twenty-four-hour virtual symposium on COVID-19. Smatterings of mis- and disinformation on the virus are mingled with efforts at dissemination of accurate information, creating a battleground for those living in fear and those who believe the world’s reaction to the virus is overblown or that the virus is a farce altogether.


How Does It Affect Our Mental Health?


In 2003, during the SARS pandemic, researchers studied the mental health of subjects who were quarantined either by order or self-imposed, as well as those who lived through the pandemic but did not experience any self-isolation or quarantine. The results of their study indicated that persons quarantined, whether by order or voluntarily, experienced higher likelihoods of depression, anxiety, and Post Traumatic Stress Disorder (PTSD) than their counterparts who lived through the SARS pandemic but were not subject to quarantine (Hawryluck et al., 2004).


In this same vein, fears of illness, death, and uncertainty of the future are significant psychological stressors for the population. Social isolation resulting from loss of structured educational and work activities also threatens to worsen mental health (Carvalho et al., 2020).


Frontline healthcare workers who face regular exposure to the illness, while at the same time working with protective equipment shortages, are forced to rapidly adapt to ever-evolving high-stress work environments (Joob & Wiwanitkit, 2020; Kang et al., 2020). That this pandemic is a potential source of direct, secondary, and vicarious trauma for everyone is further emphasized by reports of suicide deaths related to fears of contracting or spreading COVID-19 (Goyal et al., 2020; Montemurro, 2020).


Directly tied to the impending and worsening mental health crisis related to the COVID pandemic are people’s perceptions of the severity of contagion and risk of transmission (Bults et al., 2011). The ease of access to news and social media—that twenty-four-hour virtual symposium formerly mentioned—continuously assaults us as we check and recheck the news and read opinion-related pieces, see memes about the virus, and read pieces posted by people who may or may not be front-line healthcare workers claiming to bear witness, for example, to a one hundred percent rate of lethality for COVID-related hospital admissions.


These studies are interesting, as, together they point to two schools of thought which follow the same vein: i) perceptions of the severity of the virus as well as perceptions of the person’s susceptibility to the transmission of the virus, e.g. It’s killing almost everyone who gets it, and I’m going to get it; and ii) the effects of isolation during quarantine. Together, these two veins of thought equal fear-driven stress and anxiety exacerbated by all the other stressors affecting us during quarantine.


What Do Negative Mental Health Outcomes Look Like?


Amidst the pandemic and especially when facing quarantine and isolation, psychological distress is not uncommon; in fact, it is exceedingly common. You might experience fear and worry about yourself or loved ones, changes in sleep or eating patterns, difficulty sleeping or concentrating, possibly worsening chronic health problems or worsening mental health conditions; additionally, you could experience increased use of alcohol, tobacco, or other drugs. You might face angry or rebellious teenagers who don’t believe the pandemic or illness is anything to be concerned about, causing stress for you and/or other family members. Other, more specific feelings or symptoms you or others in your household might notice are sadness, numbness, insomnia, confusion, anger, PTSD symptoms, depressive symptoms including low or abnormally elevated moods (or swings in mood), emotional disturbances, irritability, and emotional exhaustion.


What Can We Do To Counteract Negative Mental Health Outcomes?


In the field of mental health, we look at what are called risk and protective factors relevant to mental health. Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with higher likelihoods of negative outcomes; protective factors are characteristics associated with lower likelihoods of negative outcomes or that reduce a risk factor’s impact. Inasmuch, protective factors mitigate risk factors. During these times of the COVID-19 pandemic, we want to look for protective factors and rely on them to mitigate risk factors as much as possible.


In addition to risk and protective factors, at the neurological level, we have two series of endocrine glands in our brains and bodies that assist in the balance of our moods and therefore contribute to positive or negative mental health outcomes. One set of endocrine glands is referred to as the HPA axis and the other is referred to as the TAP axis.


HPA (axis) is an acronym for the hypothalamic pituitary adrenal axis. The HPA axis is comprised of the hypothalamus, anterior pituitary gland, and the adrenal cortex. The HPA axis is our central stress response system; when stress levels rise, our HPA axis gives our brain and body the chemicals they need to fight, flee, or freeze. Consequently, when we face aberrant or prolonged periods of stress, such as during this pandemic and quarantine, our HPA axis habituates to the stressors and begins producing and secreting alarm chemicals and hormones, such as cortisol, corticotrophins, adrenaline, epinephrine, and norepinephrine, in amounts necessary for our body to maintain its now conditioned state of hyperarousal. This increase in alarm chemicals creates stress responses, such as increased respiration, faster and harder heartbeats, sweating, faintness or dizziness, and in some cases nausea and disassociation (that “floating” feeling or feeling like things aren’t real or you’re going to go crazy). If any readers have experienced moderate to severe anxiety, or anxiety or panic attacks, I bet some of these sound very familiar to you.


TAP (axis) is an acronym that refers to the thalamus, anterior cingulate cortex, and the prefrontal cortex. The TAP axis is our brain’s center for executive decision-making. Its axis of glands is located in the left frontal cortex of the brain and is the prime area responsible for positive emotions, such as gladness, joy, happiness, and love.


Sometimes when we are depressed or anxious, or even mad, our TAP axis is “offline,” and dysregulated, because our HPA axis has taken over during periods of stress. So, the goal during this pandemic and quarantine(s) is to regulate both our HPA and TAP axis, keep our TAP axis online, our HPA axis functioning at a normal pace and volume, and therefore our brain’s and body’s chemicals and hormones in harmony.


If you are serious about combating negative mental health outcomes, there are several actions you can take to combat them.


Routines


One way to combat these negative mental health outcomes is to stick to a routine, whatever that routine might be. Disruption to your daily routine can be one of the more difficult aspects of quarantine; a common feeling is a feeling of directionless. Plan a routine that works for you and/or your family; if your family was normally in bed by 10 PM and up at 6 AM during the week, stick to that routine. If you normally went to the gym at 3 PM, then do your workout at home at 3 PM, even if that means going for a walk or a bike ride, or something more vigorous if you can make that work for you. If need be, create a daily schedule, and stick to it.


Exercise—Or At Least Be As Active As Possible


Exercise affects certain hormones and chemicals in our bodies. Many have probably heard of “the runner’s high” or about exercise releasing endorphins that help us “feel good,” thereby elevating mood. Research, however, reports during periods of stress, when our HPA axis becomes normalized to continuous stress-response and works overtime releasing alarm chemicals that cause us to feel depressed or anxious, periods of physical activity or exercise counteracts the HPA axis’s dysregulation. What this means is that during this pandemic and/or period(s) of quarantine, regular periods of physical activity or exercise will help counteract the dysregulation of your HPA axis and keep your TAP axis “online.” For example, according to Beserra et al. (2018), exercise is indicated to decrease the amount of cortisol produced by the HPA axis during periods of stress. Moderate or higher intensity exercise has shown the most efficacy; however, even low-intensity periods of physical activity and/or exercise was shown to have efficacy in reducing production levels of cortisol.


Be Aware of and Fight or Combat Frustration and Boredom


Making plans, “staying busy,” “getting things done,” whatever you might call it or however you might approach it, staying busy and occupied is one key to fighting off the malaise and pitfalls of quarantine or isolation that can lead to sadness, despair, and boredom. We can still go for walks, mow the lawn, work on projects or hobbies, or even go for a drive. Keeping yourself busy keeps you from sitting and ruminating, as well. Working on a project or hobby, likewise, provides you something to look forward to. And, bonus, things like mowing the lawn are physical activity, and what did you just read about physical activity…?


Communication


A common turn-of-phrase is that humans are social creatures by nature; we’re not intended to be solitary. Quarantine or isolation, particularly if you already live alone, can cut off lines of communication. If you’re an introvert, this might be a plane of normalcy; for people who are not introverted, it can be a new level of discomfort and despair. Whatever the case may be for you, maintaining regular communication with someone or some people is extremely important in fighting off the malaise of quarantine. Here are some ideas for maintaining communication during quarantine:


Staying connected:


· Eat regular meals with others, if possible

· Check-in with family and/or friends at least one time per day via phone, Skype, Facetime, or whatever method works best for you

· Vary your methods of communication, e.g. voice-call one time, video-call the next, and even use text and email if those are the only methods you can reach certain contacts

· Offer support to others in need; for instance, reach out to friends or family who are feeling stressed or worried

· Use social networks—sparingly—to maintain contact, such as Twitter or Discord


Stay Informed of Goings On But Be Careful to Avoid Becoming Saturated with News and Social Media


When we don’t stay up to date on the latest information, especially during a viral pandemic, we experience greater anxiety. One common result is we then perceive a greater risk of contagion or greater severity if we do contract the virus. The answer to this is to stay informed; however, the same panic—or worse—can result from oversaturation of news and social media reports on the pandemic, particularly when we are reading or seeing mostly negative news and social pieces. The advice here is to stay informed from sources such as the Centers for Disease Control (CDC), the World Health Organization (WHO), your state and local health departments, or even contacting your family physician. The point? Avoid subjective editorials, memes, and posts, for example, on social media sites that purport to be written by experts, and instead visit the sites that provide objective, fact- and evidence-based information.


About Our Children

Bults et al. (2011) report that during the H1N1 pandemic, children who had been through quarantine exhibited PTSD symptoms at four times the rate of children who had not been quarantined.


Talk to your children about COVID-19, quarantine, and nonpharmaceutical prevention measures, e.g. why we are practicing social distancing right now. Do so in a way that is age-appropriate for your children and not panicked or worried but instead reassuring. Maintain a sense of structure at home and model healthy, positive behaviors. Remember that our children pick up their cues from parents; managing your anxiety will help calm the fears of your child(ren).


If You Need Someone to Talk to, There Are Ways to Achieve It


Last, if you find yourself overwhelmed, many mental health agencies and organizations have provided telemental health services, ranging from telephone to video-call, and/or text support. Go to my resources page. Use the website information or contact any of the national resources listed to receive information about mental health agencies in your area, and contact them to arrange speaking with a therapist, or even use one of the national resources that will assist you directly, providing support through phone, text, or video. Remember, there is nothing wrong with talking to a professional; the relief from unburdening what you’re carrying can be life-changing, especially in times of crisis.


References


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Beserra et al. (2018). Can Physical Exercise Modulate Cortisol Level in Subjects with Depression? A Systematic Review and Meta-Analysis. Trends in Psychiatry and Psychotherapy, 40(4), 360-368.


Bults, M. et al. (2011). Perceived risk, anxiety, and behavioural [sic] responses of the general public during the early phase of the Influenza A (H1N1) pandemic in the Netherlands: results of three consecutive online surveys. BMC Public Health, 11(2), 1-13.


Carvalho, et al. (2020). The Psychiatric Impact of the Novel Coronavirus Outbreak. Psychiatry Research. doi: https://doi.org/10.1016/j.psychres.2020.112902


Centers for Disease Control (2009). Origin of 2009 H1N1 (Swine Flu): Questions and Answers. Retrieved from: https://www.cdc.gov/h1n1flu/information_h1n1_virus_qa.htm.


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