The mental health toll of COVID-19 may prove to be as serious as the physical toll. One-third of virus survivors suffer neurological or mental disorders, according to a recent Oxford University study. Children, teens and young adults, Blacks and Hispanics, essential workers, and households with job loss or lower incomes are reporting high rates of anxiety, depression, and substance abuse. Even those who haven't experienced health or economic problems this past year are struggling with the pandemic's disruptions to daily life. The depth of the crisis was illustrated by recent news that drug overdose deaths, driven by opioids, are worse than ever—higher in some places even than deaths from COVID.
"We have a pandemic right now, and that is going to lead us to have a mental health syndemic," says Vickie Mays, Ph.D., a professor in psychology and health services at UCLA's Fielding School of Public Health, using a term that refer to two interrelated epidemics, or "synergistic epidemics."
"We have to think about what's necessary to get us back to a place where we're opening, we're vaccinated, but that, in addition to those two things, we're healthy mentally as well," explains Mays.
The U.S. mental health system, already difficult to access and navigate before the pandemic, is not prepared to handle this crisis. Lack of insurance or in-network coverage, or a shortage of mental health professionals, has prevented most adults who experienced serious psychological distress from seeing a mental health professional, according to the Kaiser Family Foundation.
"You cannot simply treat people one on one, and that is because we don't have enough professionals to address everyone's needs," says Olya Glantsman, Ph.D., a community psychologist at DePaul University in Chicago. "But also those who need help the most typically get it the least, either because they are excluded from health care, they cannot afford it, or the type of jobs that they work, they can't afford to take a vacation or day to decompress or do self-care."
That's compounded by a health and economic crisis that has seen millions lose insurance and paid time off, which makes taking a mental health day or seeing a therapist impossible.
However, the mental health system's deficits represent not only a crisis but an opportunity to broaden how society approaches mental health, from individualized, brain-based, and "isolated … from the broader social context" to inextricably linked to the health of our communities and society.
A subset of psychologists, social workers, and community health workers have long advocated for this approach, supporting strategies beyond medication and standard therapy, to address what they call "social determinants of health." The scale and collective experience of the pandemic, racial justice movement, and economic crisis, may be what pushes this approach into the mainstream.
Few people challenge the idea that stressful life situations like unemployment, abuse, hunger, or racism, might lead people to drink more, use more drugs, or feel depressed and anxious. But the "biomedical model" of mental health that is predominant in the American health care system focuses on diagnosing and fixing an individual and not on addressing the factors that contribute to good mental health, like safe housing, reliable food sources, or physical safety from violence.
As the British Psychological Society, the main representative body for psychologists in the U.K., recently wrote, "The pandemic has rendered visible that psychological functioning cannot be separated from the social conditions in which it takes place … If we only conceive of the impact of the pandemic at the level of the individuals' thoughts, feelings, and behaviors then we will be likely to think of solutions at the individual level too."
Psychosocial approaches to mental health get less funding and attention, but they can be just as impactful. Rochelle Burgess, Ph.D., a community health psychologist at the University College in London, has worked with colleagues in South Africa to pilot an approach, called COURRAGE-PLUS, that combines group therapy based on Ubuntu principles—an indigenous concept that recognizes the interconnectedness of individuals' well-being—with several sessions that help participants develop skills and identify resources to challenge long-standing social adversity. This includes training in how to take collective action, getting connected with legal or financial aid groups, or entrepreneurship. A group of women who'd experienced poverty, violence, and trauma, who went through this training had significantly reduced symptoms of depression.
"The COURRAGE intervention's ability to work within a non-clinical community facing high levels of social adversity, without over-emphasizing medicalized concepts of mental ill-health to the exclusion of social challenges faced within the community, is a novel approach in these settings," the study concluded.
Community-oriented approaches can also fill a void when people don't have access, or are hesitant to access, traditional mental health services. Leaders at Behavioral Health Systems Baltimore, a nonprofit that provides services for the city of Baltimore, realized last year the mental health of COVID would be significant. So the organization began partnering with faith leaders to reach people who might be mistrustful of the health system but needed support. They've led sessions in places of worship using a form of therapy called Sanctuary SELF, where participants process and identify past trauma and toxic stress in a safe communal setting.
"It's a way to open people to an approach to mental health outside of just going to see the traditional therapist. We can have these conversations in a community. Why? Because there's collective wisdom in a community. You've been through stuff, I've been through stuff. We can learn from each other," says Terri Alexander, a project manager at Behavioral Health Systems Baltimore.
A benefit of community-oriented programs is that they draw on the collective wisdom and resilience of a group, which can be lost when we focus only on individual approaches. During the pandemic, Black and Hispanic people have had higher resilience than white people, particularly poor Black people compared to their poor white counterparts, according to a Brookings study. The study credits their resilience in part to belonging to strong communities that have overcome past adversity.
"These same communities have been surviving days like this for generations," says Jaleel Abdul-Adil, Ph.D., a community psychology professor at University of Illinois-Chicago and director of the Urban Youth Trauma Center in Chicago. "We want to go in and look at, not only what are these communities' needs, but also what are the strengths and how have they helped each other. This way, we can collaborate and supplement the work they do in our community-based outreach and partnership." The Urban Youth Trauma Center recently helped organize a Youth Violence Prevention Week, which combined sports, meals, and activities with helping kids develop skills that could help prevent violence. They're also involved in a restorative justice program in Park Ridge, Illinois, which keeps nonviolent youth offenders out of the criminal justice system through a program of conflict resolution, mentoring, and community service.
One of the main ideas of a socially-oriented psychology is that it's difficult for people to have mental health if their basic needs, like safety and shelter, aren't being met. This belief underlies Housing First. Unlike other programs, people who need it are provided housing without requirements that they deal with their behavioral problems. According to studies, Housing First "shows greater improvements in terms of sustaining housing and staying healthier, compared to places that only focus on mental health first but forget about basic needs," says Glantsman.
Worries over how COVID-19 is impacting the mental health of teens and young adults—who are significantly more suicidal than all adults—has felt particularly divorced from the root causes of their depression and anxiety.Although concern about screen time and academic loss is valid, it ignores the context of a generation that faces crushing student debt, an awful job market, and a historic climate crisis.
Burgess found in a study last summer that unemployment significantly impacted the mental health of members of 18- to 24-year-olds. "These were young people who were already very aware that their success in life was that much harder. And they saw all of the pathways and roots to a brighter future drying up … It had a huge emotional toll," she says.
Strategies to support mental health could include supporting the Green New Deal, which has strong support from Generation Z and would help address the jobs and climate issues. But it currently faces an uphill climb in Congress.
"Young people come up with suggestions, like 'We need to have job training coming out of the pandemic, we need to build up local industries,' and the recommendations come out about how to improve young people's mental health, and it's, 'Get more counselors in school,'" says Burgess. "So there's this real disconnect between treating the symptoms and ignoring what people identify as the cause."
There are parallels between COVID-19 and another crisis moment in U.S. history, the aftermath of World War II. Because of screenings of recruits and combat veterans, psychiatrists and politicians discovered "that mental illness was much more rampant in American society than previously thought," according to Matthew Smith, PhD, professor of history at University of Strathclyde in Scotland. They connected these problems with poverty, class and race inequality, overcrowding in urban areas, violence, and poor education.
This led, in 1963, to President John F. Kennedy signing into law the Community Mental Health Care Act, which for the first time funded federal community mental health centers. The "strengthening of our fundamental community, social welfare, and educational programs … can do much to eliminate or correct the harsh environmental conditions," Kennedy said at the time. A year later, President Lyndon Johnson declared the War on Poverty, which led to the passage of Medicare and Medicaid and significant investment in community health.
After years of cuts to such programs, there's hope that the pendulum may finally be swinging back, especially with the election of President Joe Biden and the attention to social and structural issues in the last year.
"What we do as community psychologists is radically different but it's also very natural," says Glantsman. "We're not saying that we were the first ones to create this. Individuals and communities have done this type of work for centuries. We just want to bring it back and make it more mainstream."