Q&A: Disaster psychiatrist highlights mental health impact of COVID-19 pandemic

Key takeaways:

• The public health emergency for the pandemic is ending May 11, but the pandemic still plays a role in mental health.
• We spoke to a disaster psychiatrist to learn more.

Around the world, reports of mental health issues increased dramatically during the pandemic.

In the U.S., the public health emergency for the COVID-19 pandemic will end May 11, according to a fact sheet from the HHS.

As it ends, the effects of the pandemic on mental health will continue to be felt.

Healio spoke with Maya Bizri, MD, MPH, a disaster psychiatrist and founding director of psycho-oncology at the American University of Beirut Medical Center in Lebanon, to learn more about the impacts of the pandemic on mental health.

Healio: How do global challenges impact rates of mental illness?

Bizri: There is actually a term for it, which is disaster psychiatry. This means the reactions to any mass catastrophe, whether that’s a war, a public health emergency, a mass shooting, but also any natural disaster such as a hurricane or an earthquake. It’s important to note that, yes, rates of mental illness such as anxiety, depression, PTSD, whether that’s a new-onset or worsening of a pre-existing condition, do increase, but I think what people miss out on is that what is most prevalent are subsyndromal states. These are reactions that are not necessarily pathological or disordered, but they’re extremely impairing, and these tend to decrease after the first year.

For many patients, stress may not be related to disaster itself, but actually the post-disaster chaos that may be happening. The Institute of Medicine notes the importance of focusing not only on disaster pathologies, but also on disaster stress behaviors. These have significant long-term outcomes. These include increased smoking, increased substance use, chronic irritability without it being full-blown depression or even overwork as a response to disasters.

Globally, it’s also important to note that developing regions are inherently more prone to disasters due to other challenges they might have, such as poverty and lack of resources. In many of these regions, mental health services are already fragmented at baseline; they’re not as robust as they should be. So, disasters or global challenges impact people much worse than in more developed countries.

Healio: What impact has the COVID-19 pandemic specifically had on mental health?

Bizri: Even early on in the pandemic, the global prevalence of depression and anxiety in the first year increased by a massive 25%. That was higher for depression alone, not just anxiety — that was up to 30%. In the U.S., approximately four in 10 adults were reporting these symptoms. It went down to three out of 10 adults as the pandemic continued, but that’s still very significant. When you look at specific stressors, one major reason for the specific increase in unprecedented stress was the major social isolations, the constraints on people’s ability to work, to seek support from loved ones and to engage in their communities. Other stressors were loneliness; fear of infection; fear of suffering; fear of death, whether that’s on you or your loved ones; grief after bereavement; but also, financial stressors.

For mental health in specific — I think that’s more so a U.S. problem — we also know that drug overdose deaths have sharply increased, largely due to fentanyl and other synthetic opioids. In 2021, there were more than 100,000 drug overdose deaths in the U.S., which is the highest on record. If you talk about global health within the U.S. with discrepancies and health care inequities, these were more common in populations of color. At the start of the pandemic, there was a brief period of decline in suicide, but it went back up as the pandemic continued.

In the first WHO brief that came out early on in the pandemic, there was a focus on health care workers and how exhaustion was triggering suicidal thinking among them. So, we’re coming close to the end of the public health emergency, but it’s important to keep in mind that many people still grapple with worsened mental health and well-being and face barriers in accessing care. The most recent survey in 2023 among U.S. adults showed that 90% still believe that 3 years into the pandemic, there is very much a mental health and substance use crisis. So, that’s a problem still ongoing here in the U.S., not just globally.

Here, we’re just looking at conditions that might come as a result of the pandemic in general, not just COVID itself, not inherently related to a COVID infection and how that might affect the brain. That’s a different field as well.

Healio: Are there specific mental health conditions (ie, anxiety, depression, etc.) that have become more or less prevalent during the pandemic?

Bizri: When we’re looking at pandemics or disaster psychiatry, it’s important to focus on at-risk groups. Women and young people were the hardest hit. It was concerning because suicidality did not necessarily increase, but it was mostly self-harm behavior among adolescents, which is as serious as suicide in that it might lead to suicide. It was alarming then because it was a time when access to mental health services was becoming more and more difficult. Hospitals were largely focused on addressing COVID and they were functioning at capacity. We’re not sure why, but we think globally — because this was also found in our study in Beirut, so it’s not just a U.S. thing — that adolescents were dealing at a time with different pandemic-related consequences. They had closure of universities, they had to switch to remote work, they had a loss of income or employment, and that may contribute to poor mental health.

There were anxiety disorders more so in women. We don’t know why, but even prior to the pandemic, women were more likely to report mental health issues than men, so maybe that’s just a problem in reporting.

There was an increase in health anxieties in people who have chronic medical problems for obvious reasons: they were worried about getting infected. These were people who have asthma, cardiac problems, for example.

Drug overdoses increased sharply, and they more than doubled in adolescents. We tend to focus, especially in the U.S., on substance use as an opiate problem, but alcohol-induced death rates also increased; there was an increase by 38% during the pandemic. That’s something you can’t overlook, because most of the substance use prevention efforts have been focused on opiates and drug overdoses. These rates increased in people of color or in rural areas. So, that’s something we will still have to address.

I spoke about essential workers and health care workers; they face a sense of moral injury. It’s a specific condition that is not just dealing with trauma, but also dealing with the dilemma of worrying about being a vector and carrying the infection back to your loved ones, and also providing adequate care and doing something that would not be aligning with your moral values or your ethical compass.

What I think is going to still be a problem specific to COVID is long COVID. It’s not just the psychological responses to catastrophes and the pandemic, but COVID itself as an infection. For example, we still are not sure of the mechanism behind long COVID. We know it exists, we know it persists for 3 months or returns after an infection with fatigue and shortness of breath, but also cognitive impairment that occurs in thinking and memory as a brain fog that people describe. It’s very impairing, because it impairs their productivity. This can overlap in people who have developed what we now call post-ICU syndrome. It’s a traumatic experience that you have after being hospitalized in the critical care setting for too long. So, when you take that and add to it the brain fog that comes from having a severe COVID infection, it can be extremely debilitating without you specifically having depression or anxiety. You have these two syndromes that are COVID-specific, and I think that’s something we’re still going to have to face, especially because the literature on it is not very specific.

Healio: What challenges do mental health professionals have to overcome to address the burden of the pandemic?

Bizri: There was a major disruption in access to care for much of the pandemic. Services for mental, neurological and substance use conditions were the most disrupted among all essential services, whether in the U.S. or elsewhere. Many countries had disruptions in life-saving services for mental health like suicide prevention. I think the silver lining of this pandemic is that telemedicine boomed; there was a very rapid deployment of telehealth services. Many people have sought support online, and this is not something one can ignore anymore. Even as a psychiatrist, if you’re not a big fan of telemedicine, it’s just something you have to adopt to be able to provide care. When you talk about global health, this is still problematic because in countries with limited resources — and I know in Lebanon, it is a problem — you have disrupted services, disrupted electricity, and connectivity is glitchy most of the time, so it will increase the inequity globally in terms of access to care.

One thing I will not stop stressing is that usually mental health providers, as are all health care providers, tend to be “collateral damage,” I call it, in such settings. They are faced with a sense of moral distress, psychological distress, they tend to not take care of their own mental health, and that will only lead to worse outcomes in terms of patient care and not just their own self-care.

The other challenge was there was a sense not just in the psychiatric community, but in the overall medical community, that this is something new. The literature was very fluid and dynamic and changing — how to address the psychiatric symptoms was being rolled out as you were treating patients. There were theories coming along on how to address psychiatric symptoms such as brain fog and prolonged delirium in the ICU setting. I work in consultation psychiatry, so people who work in consultation, meaning they see consults on the medical wards, we had to keep up-to-date with the literature. It’s a lesson in humility because you’re learning with your trainees as well. So, I think that was a major challenge.

I mentioned this early on: You have to get creative around treating but not pathologizing reactions that are subsyndromal, meaning disturbances in sleep, mild attention difficulties, mild anxiety reactions, even before they become big, psychiatric symptoms or diagnosable disorders. You have to have a role as a mental health provider in being there for other frontliners because they are facing patients who are dealing with a huge amount of stress and trauma. Most health care providers who don’t have mental health training face difficulties in addressing these patients. So, even if you don’t work as a psychiatrist in trauma settings or disaster settings, psychological first aid was just something you had to learn again. That was an important challenge as well.

Healio: How should clinical practice and policies adapt to support mental health care following the pandemic?

Bizri: I read the WHO’s most recent survey and I saw that 90% of countries are working to provide mental health or psychosocial support to COVID-19 patients but also to responders, which I think is good. But we do have an unfortunate situation where there is a global shortage of mental health resources, and that was even prior to the pandemic, and it is even worse after the pandemic. On average, governments spend just over 2% of their health budgets on mental health, much less in lower- and middle-income countries. But there have been changes in the U.S. One was the growth of telehealth. Two, because of the substance use issue, there was improved access to opioid use disorder treatment. For example, they were allowing more take-home methadone dosages and covering telehealth appointments. The restrictions on who was allowed to prescribe suboxone or buprenorphine were expanded, which is great, but we should also focus on alcohol use disorders as substance use, not just in terms of policy.

Speaking of adolescents, there was an expansion of school-based mental health services in response to the growing mental health concerns among youths. There was recent legislation that provided funding to expand and train mental health providers in schools; implement suicide, drug and violence prevention programs; and provide trauma support programs for families and parents. So, I think that was a good byproduct of the pandemic.

The other important byproduct of the pandemic was an easy-to-remember number for the suicide and behavioral health crisis hotline: 988. Some states are developing behavioral health crisis response systems. So, you would have a mobile crisis or crisis stabilization unit. It will enable specialized behavioral health response for those who require an actual intervention.

Healio: What else would you like to highlight about mental health following the COVID-19 pandemic?

Bizri: One thing we have to learn from this pandemic is there is a sense of hypervigilance or hyper-alertness in terms of disaster preparedness. This was only a warning, there is bound to be another pandemic. For disaster preparedness, we have to make mental health more of an essential service, not just as a secondary service or something that is an afterthought. It highlighted — not just globally, but within the U.S. — the inequity in terms of accessing health care, whether it’s for younger people, whether it’s for people of color, for minorities and for people who were living in rural areas. So, we have to do a better job in providing access to health care, even before the next disaster strikes.

Again, I’ll never stop talking about the health care workers’ mental health; that is very important. Even though the COVID-19 pandemic as a public health emergency is stopping, we are going to still face long COVID, and we are going to still face health care worker burnout. It was just an alarm to tell us there’s something wrong with the system.

Reference:

• HHS. Fact sheet: COVID-19 public health emergency transition roadmap. https://www.hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html. Updated Feb. 22, 2023. Accessed May 3, 2023.