Jonathan Kanter wrote in the Conversation that Isolation, social distancing and extreme changes in daily life are hard now, but the United States also needs to be prepared for what may be an epidemic of clinical depression because of COVID-19.
We are clinical psychological scientists at the University of Washington’s Center for the Science of Social Connection. We study human relationships, how to improve them, and how to help people with clinical depression, emphasizing evidence-based approaches for those who lack resources.
We do not wish to be the bearers of bad news. But this crisis, and our response to it, will have psychological consequences. Individuals, families and communities need to do what they can to prepare for a depression epidemic. Policymakers need to consider – and fund – a large-scale response to this coming crisis.
A perfect storm of depression risks
Most of us know the emotional components of depression: sadness, irritability, emptiness and exhaustion. Given certain conditions, these universal experiences take over the body and transform it, sapping motivation and disrupting sleep, appetite and attention. Depression lays waste to our capacity to problem-solve, set and achieve goals and function effectively.
The general public understands depression as a brain disease. Our genes do influence how easily we may fall into clinical depression, but depression is also, for most of us, substantially influenced by environmental stress. The unique environmental stressors of the COVID-19 crisis suggest that an unusually large proportion of the population may develop depression. This pain is likely to be distributed inequitably.
Stress and loss
Exacerbating the widespread stress of this crisis, many of us are suffering significant personal losses and grief reactions, which are robust predictors of depression. The ongoing and unpredictable course of these stressors adds an additional layer of risk.
As this crisis unfolds, death tolls will rise. For some, especially those on the front lines, acute experiences of grief, trauma and exhaustion will compound the stress and place them at even greater risk.
Prolonged social isolation – our primary strategy to reduce the spread of the virus – adds another layer of risk. Our bodies are not designed to handle social deprivation for long. Past studies suggest that people forced to “shelter in place” will experience more depression. Those living alone and lacking social opportunities are at risk. Loneliness breeds depression.
Families, who must navigate unusual amounts of time together in confined spaces, may experience more conflict, also increasing risk. China experienced an increase in divorce following their COVID-19 quarantine. Divorce predicts depression, especially for women, largely due to increased economic hardship over time.
The biggest stressor for many is financial. Unemployment and economic losses will be severe. Research on past recessions suggests that rising unemployment and financial insecurity lead to increased rates of depression and suicide. debt and financial deprivation during recessions are at significant risk for depression due to increased stress and difficult life circumstances. Minority-owned businesses may be at particular risk for buckling under the strain.
Recovery will be harder
Home foreclosures during the 2008 recession produced a 62% increased risk of depression among those foreclosed.
The mental health burden of economic recession will be distributed inequitably. When the stock market crashed in 2008, the rich experienced large wealth losses but not increased rates of depression. In contrast, those who experience unemployment,
While the COVID-19 crisis increases risk for depression, depression will make recovery from the crisis harder across a spectrum of needs.
Given depression’s impact on motivation and problem-solving, when our economy recovers, those who are depressed will have a harder time engaging in new goal pursuits and finding work. When the period of mandated social isolation ends, those who are depressed will have a harder time re-engaging in meaningful social activity and exercise.
When the threat of coronavirus infection recedes, those who are depressed will face increased immunological dysfunction, making it more likely they will suffer other infections. Depression amplifies symptoms of chronic illness. The inequitable distribution of the burden of the crisis will exacerbate existing racial health disparities, including disparities in access to depression treatment.
What to do?
Self-help suggestions are readily available. A good list, more evidence-based than most, is here. It is our experience, however, that such self-help encouragements for depression are not enough, and at times even insulting, for those who are truly struggling.
We need higher-level shifts in policy and how we approach the problem. Economic relief measures from the federal government are crucial responses both to economic recession and psychological depression. We call for a public health campaign to increase awareness of depression and treatment options, and for improvements in mental health sick-leave policies and insurance reimbursement to minimize barriers to treatment access.
How we talk about depression must change. The distress we feel is a normal human response to a severe crisis. Acknowledging and accepting these feelings prevents distress from turning into disorder. Describing depression solely as a brain disease increases helplessness and substance use among those who are depressed and decreases help-seeking. Emphasizing the causal role of our environmental context, in contrast, matches how depressed individuals across different ethnicities view the causes of their suffering, decreases stigma and increases help-seeking.
Finally, we recommend specific treatment options be prioritized. As we have discussed elsewhere, easy-to-train, cross-culturally applicable and effective treatment options exist. We wish for an army of practitioners to be trained and embedded in community and treatment centers across the country, and this army should represent the great diversity of our country.
Some specific suggestions to help us all:
Protect Your Family’s Mental Health During the COVID-19 Pandemic.
Begin the Day with Gratitude
Before your feet hit the floor in the morning, think of something that you’re grateful for. Making this a focus for yourself, and teaching your kids to do the same, can have a significant impact on your emotional health. The heaviness of our current situation can quickly weigh us down, and if we begin our day with doom and gloom, then we have set the negative feeling pendulum into full swing.
A study published in the journal Psychotherapy Research found that writing a gratitude letter can improve a person’s outlook and emotional well-being. It even seems to change brain activity in a positive way, based on MRI scans of study participants.
Get into a Routine and Make a Daily Schedule
Depression and anxiety can keep you from feeling in control of your life. One way to counteract that feeling is by making a regular schedule and sticking with it. When you organize and structure your life, you know what to expect. Make sure you have a family routine.
Remember, kids are used to routine and structure in schools. Many thrive on having consistency in their lives, which consequently helps them feel in control, something kids need now more than ever.
Not only will having a plan can help you stay centered, it will keep you focused on the tasks at hand. A study published in the Annual Review of Psychology on psychological habits showed people rely on their routines and habits when they are stressed. That helps them get through difficult times, suggesting that establishing healthy routines could help with physical, emotional and mental health during difficult times like these.
So, go ahead and make a schedule. The first item on the list should be to make your bed. According to a survey by OnePoll and Sleepopolis, which provides mattress reviews, people who make their beds regularly tend to report feeling happier and more productive. Plus, if making your bed is on your to-do list, you can accomplish your first goal of the day.
How to Cope with Coronavirus Anxiety.
Get a Good Night’s Sleep
According to the National Sleep Foundation, adults need between seven and nine hours of sleep each night. And research shows the amount and quality of sleep we get has a significant impact on mental health. The amount of sleep kids need varies considerably by their age. That ranges from newborns snoozing away most of the day (14 to 17 hours recommended), to preschoolers splitting time awake and asleep (11 to 13 hours in la la land recommended), to teens who are advised to get eight to 10 hours of sleep daily, though they rarely do.
Researchers have discovered that those suffering from mental health conditions, such as anxiety and depression, are at an increased risk of insomnia. And not getting adequate rest can raise one’s risk for mental health problems.
So, during times of high stress, sleep is of utmost importance. In addition to following a routine, another way that you can ensure a healthy night’s rest for you and your kids is by making sure the whole family is active during the day.
Research from Sweden suggests that being outside is associated with a lower risk of developing psychiatric disorders. In a separate study published in the International Journal of Environmental Health Research, researchers showed that spending about 20 minutes in the park can improve your overall well-being.
Even if you can’t get to a park, just getting some fresh air – while keeping 6 feet from others outside your household – can do you a world of good.
During this stressful time, it’s important to watch what you eat. That’s because what you put into your body will affect how you think and feel. Research has long documented the positive impact nutrition has on mood and that eating well is associated with lower levels of anxiety and stress.
Research has demonstrated the benefits of eating unprocessed food and having a diet that’s high in vegetables, fruits, unprocessed grains, with fish and only modest amounts of lean meats and dairy. Studies suggest that those who eat this way have depression rates 25% to 35% lower than those who consume a traditional Western diet characterized by processed foods, lots of red meat and high intake of unhealthy fats and carbs. The saying “you are what you eat” applies as much to mental health as it does to your physical health.
In a time of uncertainty, you need to take care of your mental health. Sure, you may be more confined than you usually are, but you don’t have to let anxiety and depression consume you. Make your mental health a priority by following the measures outlined above.
Also, if you need professional help, please reach out, as there are trained professionals who would like to assist you. Don’t forget, with COVID-19, you are not alone in how you are feeling. More importantly, remember this, too, shall pass.
Depression costs the U.S. economy US$210 billion yearly. That is under normal conditions. An epidemic of depression requires a multi-faceted, multi-level response.
Are We Only Going to See More Substance Abuse and Bad Behavior Including Gambling?
I was amazed that when our Governor of the great state of Maryland shut done businesses yesterday that the liquor stores were exempt, but not my medical offices. I also noticed that the substance abuse/methadone clinic next store to my office was still open for business and as usual, very busy. I continued to wonder when my oldest daughter asked how the pandemic will affect individuals suffering from substance use problems, particularly now that many of these individuals are in forced isolation.
Yale University professor Adrian Bonenberger noted that the coronavirus quarantine means different things to different people: A necessary inconvenience. A fusion of work and home life. A leap into social media, or virtual meetings once held face-to-face. For some, it’s possible to see a silver lining: more time with one’s family, and a change to the regular routine. But for people who suffer from substance use disorder, gambling addiction, or problematic video gaming—otherwise known as internet gaming disorder—the quarantine is fraught with danger.
“People will likely be practicing social distancing per the government’s recommendation,” said Marc Potenza, Ph.D., MD, HS, professor of psychiatry, who directs Yale’s Center of Excellence in Gambling Research, the Women and Addictive Disorders Core at Women’s Health Research at Yale, and the Yale Research Program on Impulsivity. “Oftentimes stress is linked to addictive behaviors, and there can be little question that the social distancing around coronavirus or COVID-19 has been a stressful interruption of routine for many.”
For people in treatment for substance use disorder, COVID-19 could lead to the type of stress and isolation most likely to result in risky behavior.
“Everyone is trying to protect the vulnerable from COVID-19, and the only way to make that happen is social distancing,” said Ellen Edens, MD, MPH, associate professor of psychiatry. “But social distancing can also be especially harmful for people with mental conditions or substance use disorder.”
According to Edens, there is a related concern: those who depend on medications to treat a substance use disorder may fall through the cracks. Like those with an opioid use disorder who take methadone or buprenorphine, both of which block cravings, treat opioid withdrawal and prevent opioid overdose; or those with a prescription for disulfiram, a medication that causes people to become sick if they drink alcohol and is most effective when taken under direct observation. Disulfiram is unavailable nationwide, according to Edens, though the intensively monitored in-person treatment often required for best outcomes, particularly early in treatment, is also unlikely in the current context.
Edens also notes that the most vulnerable moment for someone with substance use disorder is at the beginning of treatment, when they are deliberately and intensely plugged into group therapies and peer support groups like those popularized by Alcoholics Anonymous or AA. “With social distancing, one of the key components of addiction treatment—the reforging of family, social, or professional connections that may have been severed, exemplified by ‘network therapy’ or a ‘community reinforcement approach’—is lost,” she said. “The psychiatric community is doing what it can to make up for the sudden disruption of tested and effective in-person programs with things like old fashioned telephone calls. But between the technology gap with older patients and specific challenges faced by patients for whom disconnection is essentially the greatest danger, it’s difficult. Many AA groups that have closed their doors to comply with the injunction against gatherings of numerous people, and while it’s certainly prudent, it also leaves many attendees adrift.”
Another possible fallout from COVID-19 stems from the shutdown of casinos across the United States, coupled with the postponement or cancellation of professional sporting events including the NBA, NHL, MLS, and MLB (suspended), the Masters (postponed), the Boston Marathon (postponed), and the NCAA men’s and women’s basketball tournaments (canceled). Although gambling and sports gambling have been online and lightly regulated for years, there has never been an absolute vacuum of physical gambling locations. It’s likely that in the absence of a physical space in which to gamble, and without many of the typical outlets for gambling in place, some people with gambling addition will make their way to the internet.
The rise of e-sports is one possible place where online gambling and problematic video gaming could converge. A growing field with audiences for a single event in the millions, and over $1 billion in revenue as of 2019, e-sports, in which people play video games online competitively, requires no crowds, and can be accessed by anyone with a smartphone or laptop.
“A quarantine, particularly at home, may lead to bingeing on video games, alcohol, or drugs given the significant change to routine life. It could also lead to a relapse for those who had been doing well previously. Second, those who may have been considering coming to treatment now may suddenly be hesitant given possible exposure to the virus in a hospital or treatment setting and have decided to delay getting help,” said Brian Fuehrlein, MD, Ph.D., FW ’13, associate professor of psychiatry and director, Psychiatric Emergency Room, VA Connecticut Health Care System. Fuehrlein was careful to echo his colleagues in underlining the necessity of home quarantine and the importance of following it, and was unequivocal about the dangers posed to vulnerable populations like those who will be significantly economically impacted by social distancing.
There has already been an observable change in normal behavior at the VA, according to Fuehrlein—and the opposite of what one might expect, which is more cases. Fewer patients have been coming in for any reason, which does not bode well for long-term mental wellness. “Currently, we are seeing an uptick in those who were considering treatment for substance use disorder but have now decided to stay home instead (and thus are likely continuing to drink or use). Our census in the psych ER has actually been running lower than average,” said Fuehrlein.
In the long run, this will almost certainly turn into a large problem, or even a secondary epidemic for people already suffering from the various diseases of addiction. “I think in the long run we will see a sharp increase in depression, anxiety, and addictions of all types as a direct consequence of the current pandemic,” said Fuehrlein. “This may be due to the death of a loved one, a financial crisis, the loss of a job or housing, or some related tragedy. At the moment those consequences have yet to play out.”
Potenza echoes Fuehrlein and Edens’ concerns for people suffering from substance use or gambling problems at home, away from the usual forms of treatment. He brought up another population that will be at risk—in addition to the tens of millions of American workers (over 18% of the work force, according to an article published March 17, 2020 in the Los Angeles Times), millions of school children who have been cut loose with weeks of unstructured time. Without supervision, these groups will be especially vulnerable to what the DSM-5 defines as internet gaming disorder, on top of the better-known associated substance use disorder.
Said Potenza, “Oftentimes, it appears that people who are experiencing negative mood states or life stressors may turn to gambling, gaming, or use various substances including alcohol and drugs. COVID-19 is almost certainly creating more stress, and while health professionals and the government are mobilizing to address the threats posed by the virus, some of the recommended actions like social distancing and staying at home seem likely to lead to more gambling, more gaming, and more substance use.”
Almost 20 million American adults suffered from substance use disorder in 2017, while nearly 10 million American adults struggled with a gambling problem as of 2016. Both groups, in which there is almost certainly some overlap, rely on a therapeutic model that relies on person-to-person meetings. Potenza, Edens, and Fuehrlein all agreed that patients suffering from mental illness and substance use disorder could receive effective treatment via phone or computer, and that technology was racing to keep up with the changing demands of quarantine and the patient population. Any mechanism by which a connection could be forged, according to them, was preferable to isolation during the search for an effective vaccine and perhaps a cure.
“Ultimately,” said Potenza, “we don’t know what will happen. And that’s a source of stress for most if not all of us.”
It’s stockpiling, but not as you know it. Why coronavirus is making people hoard illegal drugs
Ms. Emma Reynolds of London (CNN) wrote that it’s not just toilet roll that people are panic buying. Some illegal drug users are reportedly stockpiling their substance of choice as restrictions intended to stop the spread of coronavirus disrupt the international supply chain.
And the consequences could be devastating, with experts concerned that people will adopt riskier habits, substitute unfamiliar drugs or enter withdrawal, which can be dangerous if unmanaged. Since heavy users often have other health problems, this could mean increased strain on services that are already near breaking point.
UK drug policy and crime experts told CNN they were worried over a growing number of reports of shortages and escalating prices for drugs, as international borders close and supply lines are cut off.
“There are reports coming through of people stockpiling their favorite drug or their drug of choice, and of course, that just creates a shortage, which has inevitably led to price increases,” Ian Hamilton, senior lecturer in addiction and mental health at the University of York, told CNN. He said he expected to see heroin “disappearing very, very quickly” in the UK.
Steve Rolles, senior policy analyst at the Transform Drug Policy Foundation, told CNN there was “anecdotal evidence of price rises… and that doesn’t seem surprising.”
“It does seem likely that the supply of drugs that these people are using, in particular heroin, is going to be restricted … it’s going to be more challenging to move drugs around.
“As weeks stretch into months, I think we’re likely to see a drought, a heroin drought.”
Alex Stevens, criminal justice professor at the University of Kent, told CNN that in areas including Birmingham and Bristol, users of heroin and synthetic cannabinoids “are reporting that they’re getting less in a £10 ($12) bag than they would have done four or five weeks ago.”
But this is an industry that operates on supply and demand. The dark web and sites including Craigslist are still active, with many users buying drugs through the mail at a time when police are not focused on monitoring post, according to several experts. “If the heroin isn’t available, they will probably find another route, whether it’s alcohol or inhalants, or benzodiazepines or something else,” said Rolles.
Rolles has even heard reports of dealers dressing in nurse’s uniforms and supermarket uniforms to make deliveries unnoticed.
What happens during a drought?
When the UK last experienced a heroin drought in 2010-11, the drug’s purity at “local dealer level” fell to 18%, according to the National Crime Agency. Street prices reportedly increased, and there was a reduction in the number of deaths involving heroin and a simultaneous (but smaller) increase in deaths involving methadone.
That may sound positive, but the experts say the effects could be different this time. Users may move from less dangerous drug-taking methods to injecting. They may use lethal combinations of drugs. They may use too much of their stockpile. And they may be more likely to overdose alone because of social distancing.
Women are using code words at pharmacies to escape domestic violence during lockdown
One vital difference between 2010 and 2020 that is causing anxiety among the experts is the proliferation of fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and can therefore be transported in much smaller quantities. The drug has not yet become widespread in countries including Britain, but is wreaking havoc in the United States.
Fentanyl is the drug most often involved in overdoses in the US, according to the National Center for Health Statistics. The rate of overdoses involving the opioid skyrocketed by about 113% each year from 2013 through 2016. If you’re used to heroin and you take fentanyl, “the risk of overdose is extreme,” said Hamilton.
The drug is often manufactured in China, but little is moving out of the original coronavirus epicenter. It is also manufactured in Mexico and possibly Eastern Europe.
With many drug users dealing with mental health issues such as depression and anxiety, coronavirus isolation presents an unprecedented challenge.
“People who have an active disorder, addiction disorder, they’re going to look for ways to get a drug,” Cynthia Moreno Tuohy, executive director at NAADAC in the US (National Association for Alcoholism and Drug Abuse Counselors), told CNN.
Asking for help
The suicide rate in the United States has seen sharp increases in recent years. Studies have shown that the risk of suicide declines sharply when people call the national suicide hotline: 1-800-273-TALK.
There is also a crisis text line. For crisis support in Spanish, call 1-888-628-9454.
The lines are staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. The confidential environment, the 24-hour accessibility, a caller’s ability to hang up at any time and the person-centered care have helped its success, advocates say.
The International Association for Suicide Prevention and Befrienders Worldwide also provide contact information for crisis centers around the world.
Tuohy expects more “poly-use” of readily available marijuana and alcohol, which is already seeing increased consumption worldwide.
It takes longer to build up data on illegal drug consumption, but analysts are watching closely.
Federal confidentiality laws in the US have been relaxed to allow people to access counseling and peer support faster. NAADAC is offering telehealth training, and resources to help clients find services available in their state.
“Whenever there’s a natural disaster, we know that relapse goes up, because of anxiety, the fear of the unknown,” said Tuohy. “Now we have an ongoing, natural disaster, if you will.
“The longer a crisis goes on, the less hope that people see … it doesn’t feel like there’s going to be a light at the end of the tunnel.
“Long term, we’re likely to see suicide go up as a result of depression. So I know that the suicide centers are gearing up and the suicide hotlines already are taking calls.”
A vulnerable population
Any disruption to the illicit drug supply will have the biggest effect on the most vulnerable populations. Heavy drug users are more likely to live with multiple people, have respiratory or other health issues or be homeless — and are therefore more at risk of contracting Covid-19.
“They are in a double tier of vulnerability in that they’re more likely to get the virus and they’re more likely to be affected negatively by it,” said Rolles. “So there’s a big responsibility, I think, on society to look after and protect those populations.”
If that doesn’t happen, hospitals and treatment facilities will face a huge additional strain, he warns.
Governments are conscious of the risks. The UK government has asked local authorities to house all homeless people. Low risk and pregnant prisoners are being released across the world.
Facilities in the US, UK and Canada are allowing stable users to pick up supplies of addiction treatment medications like methadone and buprenorphine once a week or every two weeks instead of daily, but this also presents risks.
Mat Southwell, a drug user and global advocate from Bath in southwest England, told CNN he was delivering a methadone prescription to a woman who cannot pick it up for herself, is suicidal and self-harms. She had gone three days without it.
Coronavirus is revealing how badly the UK has failed its most vulnerable
Will Haydock, from Public Health Dorset also in southwest England, told CNN that UK clinics were seeing an increase in people accessing treatment. He said this was encouraging but warned that for providers already making “significant changes to service design” this was adding to pressure. “It’s going to be a real challenge to deal with that influx of people who want support,” he said.
“This is a particularly vulnerable group of people, and you’re looking at services that are already really stretched.
“If we’re not able to offer the kind of level of support that we would like to, we will see more people die earlier than they need to.”
A spokesperson for the UK’s Home Office told CNN it is “monitoring the impacts of coronavirus” and law enforcement are “continuing to prevent drug trafficking and are successfully disrupting the drugs supply within the UK.”
The world was already facing a drug crisis before the coronavirus pandemic. The US is in the throes of an opioid epidemic. An estimated 10.3 million Americans ages 12 and older misused opioids in 2018. In 2017, there were more than 70,200 overdose deaths in the US and 47,600 of those deaths involved opioids.
The UK has seen near-record levels of drug-related deaths for six years in a row, and Scotland’s death rate is the highest in the European Union.
“I’m very apprehensive about what’s happening right now and what’s going to happen over the next few weeks to this group of our society who are extremely vulnerable, who’ve been exposed to adverse experiences, neglect and abuse from childhood onwards, and now risk being put at the back of the queue for support when in fact, they should be in front of it,” said Stevens, from the University of Kent.
The coming weeks and months will be crucial in identifying the effects of coronavirus on illegal drug use, alcoholism, suicide, domestic abuse, anxiety, and depression — and what it means for all of us as well as how we need to compromise, care and treat each other.